Citations in Oklahoma
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Oklahoma.
Statistics for Oklahoma (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Oklahoma
A required discharge assessment was not completed or transmitted for a resident who was discharged to home, despite documentation showing the resident was cognitively intact and discharge planning was in progress. The omission was confirmed by the MDS coordinator upon review of the clinical record.
A resident admitted to hospice care for late effects of a cerebrovascular accident did not have their significant change MDS assessment accurately coded to reflect a life expectancy of less than six months or their hospice status, despite a physician's order and confirmation by the MDS coordinator.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors observed three treatment carts left unlocked and unattended in different areas near the nurse's station and front entrance. An LPN was seen leaving a cart unsupervised while retrieving supplies, contrary to facility policy requiring carts to be locked and supervised at all times. Facility leadership confirmed the expectation that carts remain secured.
A resident with multiple medical conditions and moderate cognitive impairment was transferred to the hospital for an acute CVA, but the family representative was not notified by facility staff as required by policy. The LPN involved did not document or communicate the transfer, and the family only learned of the event from the medical flight pilot. The DON confirmed the lapse in notification.
A resident who missed 77 doses of cancer medication was not included in the facility's QAPI activities. Despite policies requiring ongoing quality monitoring, the missed medications and the resident's cancer diagnosis were not discussed in recent QAPI meetings, as confirmed by interviews with the ADON and DON.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident's care plan was not updated to include a new breast cancer diagnosis or related interventions, despite facility policy requiring care plans to be revised after significant changes in condition. The omission was confirmed by both the ADON and DON during review.
A green capsule in a medication cup was found left unattended on top of a medication cart in the Southeast Hallway. An LPN stated they had intended to administer the medication to a resident but forgot, leaving it unsecured and accessible, contrary to facility policy requiring medications to be secured and accessible only to authorized personnel.
Two residents did not receive medications as ordered, including insulin, magnesium oxide, ciprofloxacin, and metoprolol. Staff were unable to explain documentation marks or provide consistent reasons for missed or held doses, and one resident reported not always receiving requested medications. Interviews revealed confusion among staff regarding medication administration procedures and documentation.
Failure to Complete and Transmit Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge assessment for one resident who was discharged to home. Record review showed that a 5-day assessment indicated the resident had intact cognition and was actively being prepared for discharge. However, after the resident was discharged, there was no evidence in the electronic clinical record that a discharge assessment had been completed. During an interview, the MDS coordinator confirmed that the discharge assessment should have been completed but was not.
Inaccurate Coding of Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for one resident who was admitted to hospice care. The resident, who was cognitively intact with a BIMS score of 15, had a physician's order for hospice admission due to late effects of a cerebrovascular accident. However, the significant change MDS assessment did not reflect the resident's life expectancy of less than six months, as required, and was not coded to indicate the resident's hospice status at the time. The MDS coordinator confirmed that the assessment was related to the initiation of hospice services but acknowledged that the MDS was not accurately coded to reflect the resident's current condition.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Unlocked and Unsupervised Treatment Carts
Penalty
Summary
The facility failed to ensure that three treatment carts were locked and supervised in accordance with facility policy and professional standards. On multiple occasions, surveyors observed treatment carts left unlocked and unattended in various locations near the nurse's station and the front entrance. One LPN was seen walking away from an unlocked cart to retrieve medication cups, leaving the cart unsupervised and accessible. The facility's policy requires medication carts to be locked at all times when not in use or out of the nurse's view, and this was confirmed by both the ADON and the LPN during interviews. The DON reported that there were no wanderers in the facility at the time.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure that responsible parties were notified of a change in condition for one resident. According to facility policy, a nurse is required to notify the resident's representative within twenty-four hours of a change in the resident's medical or mental condition, unless otherwise instructed by the resident. In this case, a resident with diagnoses including atrial flutter, epilepsy, nutritional disorder, and chronic kidney disease, and with moderately impaired cognition, was sent to the emergency room following a physician's order. Documentation showed that the resident was admitted to the hospital with an acute cerebrovascular accident. Despite the facility's policy, there was no documentation in the resident's progress notes indicating that the family representative was notified of the hospital transfer. The family representative confirmed they were not informed by facility staff and only learned of the transfer from the medical flight transport pilot. The LPN involved acknowledged the lack of notification and documentation, and the DON confirmed that the family was not notified by staff at the time of the transfer.
Failure to Include Missed Cancer Medications in QAPI Activities
Penalty
Summary
The facility failed to include a resident who missed 77 cancer medication doses in its Quality Assurance and Performance Improvement (QAPI) activities. Record review and staff interviews revealed that, despite the facility's policy requiring an ongoing, data-driven QAPI program focused on care outcomes, the resident's missed medications and cancer diagnosis were not discussed or addressed in recent QAPI meetings. The Assistant Director of Nursing (ADON) indicated that the QAPI process was not initiated for the missed cancer medications because the issue was not known at the time. The Director of Nursing (DON) confirmed that the resident's cancer diagnosis and related interventions were not included in the QAPI meetings held during the relevant period.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Update Care Plan Following New Cancer Diagnosis
Penalty
Summary
The facility failed to update the care plan for one of three sampled residents, specifically neglecting to include a diagnosis and interventions for breast cancer after a physician consultation identified this condition. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, including after significant changes such as a new diagnosis. Despite this, the most recent care plan for the resident did not reflect the cancer diagnosis or any related interventions. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed during interviews that the care plan lacked the necessary updates, in contradiction to facility policy.
Unattended Medication Left on Cart
Penalty
Summary
A medication security deficiency occurred when a green capsule in a plastic medication cup was observed left unattended on top of a medication cart in the Southeast Hallway. The medication cart was not attended by staff at the time of observation. According to facility policy, medications are to be accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. An LPN later confirmed they had left the medication on top of the cart with the intention to administer it to a resident but forgot, acknowledging that the medication should have been secured inside the cart and not left unattended.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to administer medications as ordered for two of three sampled residents reviewed for medication administration. For one resident with type 2 diabetes mellitus, the medication administration record indicated that insulin glargine was not administered as ordered on a specific date, with staff unable to explain the meaning of the documentation mark used. There was no documentation that the insulin was given, and staff interviews confirmed uncertainty about the record and the process for documenting refusals or missed doses. For another resident with diagnoses including congestive heart failure and atrial fibrillation, there was no documentation that magnesium oxide was administered over a three-week period. Additionally, the medication administration records for ciprofloxacin and metoprolol showed missed or held doses, with staff unable to consistently explain the reasons for these actions or the documentation used. The resident reported sometimes not receiving medications even when requested. Staff interviews revealed confusion about medication parameters, documentation codes, and the process for holding or administering medications, with the DON confirming that some medications were not administered as ordered.
Some of the Latest Corrective Actions taken by Facilities in Oklahoma
Facilities implemented several corrective actions to address these deficiencies and prevent future occurrences.
- Staff were in-serviced on abuse prevention policies, reporting procedures, and the prohibition of using personal electronic devices, as well as the policy against taking and posting photos or videos of residents on social media. (L - F0600 - OK)
- The facility conducted an assessment of all residents to identify any potential abuse, educated staff on reporting sexual behaviors and when to report incidents, updated care plans to reflect monitoring for sexual behaviors, and ensured that evaluations for capacity to consent to sexual activity were completed for the involved residents. (J - F0600 - OK)
- Immediate actions were taken to protect residents from an aggressive resident, including transferring the resident to a hospital for evaluation and treatment. Staff received additional training on reporting and documenting suspected abuse, and care plans were updated to reflect residents' behavioral issues and necessary interventions. (J - F0600 - OK)
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by staff members taking compromising photos and videos of residents during personal care. This incident involved five residents, all of whom had varying degrees of dementia, making them particularly vulnerable. The inappropriate actions were discovered when photos and videos were posted on social media, leading to an investigation by the Oklahoma State Department of Health. The facility's policies on abuse prohibition and the use of electronic devices were not adhered to by the staff involved. The abuse prohibition policy clearly states that residents have the right to be free from any form of abuse, while the electronic devices policy prohibits personal use of such devices in the facility. Despite these policies, three CNAs took photos and videos of residents during personal care, violating the residents' rights and the facility's policies. The incident was initially reported on April 5, 2024, and involved three CNAs who were subsequently separated from employment. The facility's failure to enforce its policies and protect residents from abuse and neglect resulted in a past noncompliance finding. The deficiency was further highlighted by the discovery of additional photos and videos of four more residents, indicating a broader issue of noncompliance with the facility's policies and procedures.
Removal Plan
- Staff was in-serviced on abuse, reporting abuse, the use of cell phones while caring for residents, and taking pictures and videos of residents and posting on social media.
- Management completed the in-service and training for all staff members at the facility.
- Cell phone random audits were conducted to ensure no cell phones were being used while on shift or in resident care areas.
- Reviewed abuse policy and procedures, neglect, cell phone policy, and video policy during the Quarterly QA Meeting.
Immediate Jeopardy Due to Unsafe Shower Room Conditions
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a memory care unit due to the facility's failure to ensure the shower room door closed and locked automatically, preventing residents from entering unsupervised. During an initial tour, the shower room was found with a wet and slippery floor, a plugged-in hair dryer placed in the grab bar area, and more than ten bottles of shampoos, conditioners, alcohol-based surface cleaner, and shaving cream covering over half of the shower bench. Additionally, the cabinet in the shower room was unlocked, with razors within reach, and two emergency call lights were looped around grab bars, rendering them unusable for alerting staff for assistance. The Director of Nursing (DON) identified that 28 residents resided on the memory care unit, all potentially affected by these hazards. An LPN confirmed that the shower room door was supposed to be shut and locked, the hair dryer should not have been plugged in, and chemicals should not have been present. The running water was acknowledged as a hazard, and the call lights should not have been wrapped around the grab bar. It was also stated that residents were not to be in the shower room without staff supervision.
Removal Plan
- The shower room door was trimmed to ensure self-closure.
- The hair dryer had been removed from the grab bar and locked in the shower room cabinet. The hair dryers were removed from the locked cabinet and completely removed from the shower room.
- The ten bottles of shampoos, conditioners, alcohol-based surface cleaner and shaving cream were removed from the shower room.
- The cabinet in the shower room was locked.
- All nursing team members in the building were educated, and all remaining team members were educated. Proof of education is attached.
Failure to Prevent Falls Resulting in Major Injuries
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident had a non-injury fall on 04/11/24, but hourly checks were not documented as completed. This resident subsequently fell again on 04/14/24, resulting in a broken neck. Additionally, on 05/17/24, the resident's call light was found unplugged and placed on top of a dresser, out of reach. Another resident experienced a fall with minor injury on 04/20/24, but no interventions were developed following the fall. This resident fell again on 04/23/24, resulting in a broken back. The intervention to move the resident closer to the nurse's station was not implemented due to room availability, and no new interventions were put in place. The facility's fall policy required nurses to complete an incident report and initiate fall interventions for fall prevention. However, the records showed that these steps were not followed. For the first resident, the hourly checks were not documented, and the call light was not kept within reach, as required by the care plan. For the second resident, there was no incident report or updated care plan following the initial fall, and the intervention to move the resident closer to the nurse's station was not documented or implemented. The deficiencies were confirmed through observations, record reviews, and interviews with staff. The Director of Nursing (DON) identified that 51 residents resided in the facility. The facility's failure to develop and implement appropriate fall prevention interventions led to significant injuries for the two residents involved. The Oklahoma State Department of Health was notified, and the IJ situation was verified and communicated to the facility's administrator.
Removal Plan
- Placing all residents on checks relating to prevention of falls it will be documented on TAR's
- Call light for Res #1 has been secured so it cannot be unplugged.
- Resident #2 have relocated her room across from nurse station.
- All staff has been in-serviced on new policy and procedure for fall prevention and falls.
- All nurses have been in-serviced on development and implementation of fall interventions and updated fall procedure.
- Every resident will have a new Fall Risk Assessment completed.
Failure to Evaluate Capacity for Consent in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to evaluate two residents for their capacity to consent to sexual activity, leading to an immediate jeopardy situation identified by the Oklahoma State Department of Health. Resident #18, who had a history of sexually inappropriate behaviors and was diagnosed with unspecified dementia, was observed engaging in sexual activity with Resident #51, who had severe cognitive impairment due to Alzheimer's Disease. Despite these observations, there was no documentation of an evaluation of their capacity to consent, nor were there care plans or assessments addressing their sexual activity. The facility's policy on Abuse, Neglect, and Exploitation, which includes guidelines for preventing sexual abuse and ensuring residents' capacity to consent, was not adhered to. The policy requires establishing a safe environment and documenting determinations of capacity to consent to sexual contact. However, the facility did not provide evidence of such evaluations or incident reports to the state health department, even after multiple incidents involving Resident #18's inappropriate sexual behaviors were documented in behavior notes. The Director of Nursing (DON) acknowledged that both residents had severely impaired cognitive abilities, yet no interventions were put in place to address the risk of sexual abuse or to update the residents' care plans to reflect their sexual behaviors. The facility's inaction in assessing and documenting the residents' capacity to consent to sexual activity, despite clear indications of cognitive impairment, resulted in a deficiency with the potential for more than minimal harm.
Removal Plan
- All staff are inserviced on sexual behaviors with residents with decreased BIMS and when to report incidents.
- Designee began assessing all BIMS greater than 9 in the facility for any sexual abuse from resident #18. All residents assessed had not had any form of sexual abuse while in the facility.
- Compliance with reporting allegations of abuse/neglect/exploitation policy has been reviewed with all staff. All staff have been inserviced and all new hires will continue to be inserviced upon hire.
- MDS updated Resident #18 care plan for sexual behaviors. Monitoring order in place every shift.
- Designee will review 24 hour reports and will report any new behaviors in morning meetings.
- Nurse Practitioner to evaluate and treat Resident #18. Resident evaluation to consent to sexual activity and sexual consent form was completed on Resident #18 and Resident #51.
- DON reviewed all behavior notes assessing for any resident to resident sexual abuse. No other instances were found.
- Resident #18 and Resident #51 were educated on sexual activity.
- Nursing staff will initiate the Evaluation for Sexual Consent Form upon any observed sexual behaviors between residents.
- Follow up regarding Resident #18 sexual consent, family consented to companionship but not the act of sex itself. Follow up regarding Resident #51: Family consented to companionship but not the act of sex itself.
Failure to Supervise Resident with Unsafe Smoking History
Penalty
Summary
An Immediate Jeopardy situation was identified at a facility due to the failure to supervise a resident with a known history of unsafe smoking. The resident, who had dementia and required supervision while smoking, was admitted to the hospital with second and third-degree burns after catching on fire while smoking a lit cigarette in their room. The facility's policy required that residents who needed supervision with smoking have their smoking materials maintained by nursing staff, but this was not adhered to in the case of the resident. The resident's care plan documented that they required supervision while smoking and that their smoking supplies were to be stored on the nurse's cart. Despite this, the resident was able to access a cigarette and lighter, leading to the incident. Prior to the incident, there were multiple documented instances where the resident attempted to smoke unsupervised, refused to wear a smoking apron, and was non-compliant with the facility's smoking policy. Staff frequently reminded the resident about safety and requested assistance as needed, but these measures were insufficient to prevent the incident. Interviews with staff and other residents revealed that the resident had previously attempted to smoke inside the building and had been seen smoking unsupervised. Staff reported that the resident was non-compliant with care and smoking policies, and there were no effective interventions in place to prevent the resident from accessing smoking materials. The facility's failure to ensure the resident did not have access to smoking materials and was supervised during smoking led to the resident sustaining severe burns.
Removal Plan
- Social Services conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status.
- Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status.
- Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status.
- The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision.
- The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers.
- The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status.
- The Administrator attended the Resident Council to review the smoking policy with the residents.
- The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials.
- The DON and the Administrator conducted a smoking in-service for all employees. Ongoing education will be provided to new staff and as needed.
- The Administrator conducted QAPI to discuss the smoking policy and procedure.
- Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers.
- The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions.
- Admissions and Social Service will review the smoking times and policy with each new admission.
Failure to Provide Timely Wound Care Orders
Penalty
Summary
The facility failed to ensure timely wound care orders for two residents, leading to the worsening of their conditions. Resident #10, who had a history of traumatic brain injury, type two diabetes mellitus, dementia, and muscle weakness, developed an unstageable pressure ulcer on the right hip. Despite being at risk for pressure sores, as indicated by a Braden Scale assessment, the facility did not obtain or implement appropriate wound care orders in a timely manner. The resident's condition was documented to have worsened over time, with multiple notes indicating the presence of pressure sores and the lack of effective treatment. Resident #17, diagnosed with heart disease, dementia, and chronic kidney disease, was also affected by the facility's failure to provide adequate wound care. The resident was identified as high risk for pressure sores, yet there was no documentation of a skin assessment or wound care from mid-July until the end of the month. The resident's right heel developed a blood blister, and despite the presence of dressings provided by hospice, there were no physician orders or documentation of treatment being administered. The facility's staff, including LPNs and the DON, were aware of the residents' conditions but failed to take appropriate action to secure necessary wound care orders. Communication issues with hospice and a lack of proactive measures to obtain orders from the facility's medical director contributed to the deficiency. The facility's inaction resulted in the worsening of the residents' wounds, as evidenced by the observations and interviews conducted during the survey.
Removal Plan
- Immediate action was taken to protect residents at risk of serious injury, harm, impairment or death.
- Orders were obtained for the appropriate wound care.
- All nursing staff, including hospice personnel, were notified of the deficient practice and educated on the importance of timely, and effective communication.
- Nursing Center staff was educated on obtaining orders from facility Medical Director in the event of not being able to obtain orders from a hospice medical director.
- Baseline skin assessment completed and documented on all residents residing in the facility.
- Facility policy regarding wound care was reviewed by members of the IDT.
- Nursing Center will perform weekly skin assessments on all residents and document in skin assessments as well as in narrative format.
- Any resident with a known wound will have photo documentation under the miscellaneous tab in the EHR.
- Additional training regarding skin integrity, wound prevention, reporting, and chain of command will be completed with ALL staff by the in-service training.
- The Director of Nurses will perform chart audits and QA all orders and notes on every patient.
- The Director of Nurses will delegate chart audits to a registered nurse to assist in accurate and timely documentation.
- Residents having an area of concern or wound will be assessed and documented.
- Resident care plans will be updated to reflect the area of concern with skin integrity.
- Results of the audits will be reviewed by the QA Committee.
- Orders were received upon notification of the deficient practice.
- Nursing Center will educate and in-service all ancillary staff, to include hospice providers on orders being received and in place.
- Policy review and staff training regarding wound care and facility policies and procedures will be completed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with severe cognitive impairment who exhibited aggressive and sexually inappropriate behaviors towards other residents. This resident, diagnosed with dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in multiple incidents of physical and sexual abuse against other residents, all of whom had moderate to severe cognitive impairments. The incidents included hitting and inappropriate sexual touching, which were documented in progress notes and assessments. Despite the repeated occurrences of abuse, there was a lack of documentation indicating that all necessary parties, including state agencies, families, and physicians, were notified of these incidents. Additionally, there was no evidence that the affected residents were assessed for injuries following the altercations. The facility's failure to report these incidents and assess the residents for injuries highlights a significant deficiency in their abuse prevention and reporting protocols. The facility's policies on abuse, which mandate thorough investigation and documentation of suspected abuse, were not adhered to. The DON and Administrator acknowledged that the incidents were not reported as required, and the behaviors of the aggressive resident were not discussed in the facility's QA meetings. This oversight contributed to the ongoing risk of harm to residents, as the aggressive behaviors were not adequately addressed or mitigated.
Removal Plan
- Immediate action to protect residents at risk from abuse from Resident #3.
- Agreement between the facility and a hospital to take Resident #3 for evaluation and treatment to remove any threat of harm.
- Resident #3 taken to the hospital by a family member.
- Staff responsible for reporting and documenting suspected abuse will receive additional training.
- Care Plan for Resident #3 will be updated to reflect behavioral issues and necessary interventions.
- Facility policy regarding abuse reviewed by members of the IDT.
- Additional training regarding abuse, prevention, reporting, and chain of command will be completed with all staff.
- Nurses will receive training specific to their duties and responsibilities.
- If Resident #3 returns to the facility, a staff member will be assigned by the Charge Nurse to conduct one-on-one monitoring of the resident to ensure they are prevented from harming or abusing other residents until final discharge.
- Policy review and staff training regarding abuse and facility policies and procedures will be completed.
Failure to Prevent Elopement and Secure Treatment Carts
Penalty
Summary
The facility failed to prevent the elopement of a resident diagnosed with dementia, who was identified as being at risk for elopement. The resident, who had a history of exit-seeking behavior, managed to leave the facility without staff knowledge and was returned by a community member. Despite multiple progress notes indicating the resident's attempts to leave the facility, the staff did not implement adequate monitoring or environmental interventions to prevent elopement. The care plan for the resident was not revised to address the risk, and there was no consistent plan in place to monitor and prevent further elopement. Additionally, the facility did not complete a baseline care plan for the resident upon admission, and the 72-hour portion of the wander risk assessment was incomplete. The facility's documentation was lacking, as evidenced by missing hourly resident check forms for several dates, indicating a failure to consistently monitor the resident. Observations revealed that the resident continued to wander the halls and approach the front door without staff intervention, further highlighting the lack of adequate supervision. Furthermore, the facility failed to ensure that treatment carts were locked and supervised. On multiple occasions, treatment carts were observed unlocked and unsupervised, posing a potential safety risk. Staff members acknowledged that the carts should be locked when not in use, but this practice was not consistently followed, indicating a lapse in adherence to safety protocols.
Removal Plan
- A notification sign will be placed on front door and service door to alert visitors and vendors to not let anyone out without notifying/asking facility staff first.
- All staff In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, properly performing 1:1 monitoring, and location of list of wandering/elopement risk residents and to check list at beginning of shift.
- MDS Coordinator in-serviced on completion of care plans on all new admissions to include but not limited to potential for risk of elopement.
- HR/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page.
- Nursing Administration In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly during clinical meeting.
- DON/Designee will report any negative findings to QAPI.
- Any employee that can't be reached for In-Service will be inactive and taken off of schedule until education is provided.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who was designated as full code status, leading to a deficiency. The resident, who had diagnoses including congestive heart failure, pneumonia, and dyspnea, experienced a significant drop in oxygen saturation levels. Despite the resident's full code status, CPR was not initiated, and emergency services were not contacted. The resident's oxygen saturation dropped to critically low levels, and the resident eventually passed away without receiving CPR. The deficiency was exacerbated by the lack of awareness and verification of the resident's code status by the nursing staff. LPN #1, who was responsible for the resident's care, was not aware of the process to check or verify a resident's code status and was incorrectly informed by another nurse that the resident was a Do Not Resuscitate (DNR). This misinformation led to a failure to initiate CPR when the resident's condition deteriorated. Additionally, the LPN was unaware of the standard requirement to start CPR on residents with unknown code status until EMS or a provider stopped CPR. Multiple staff members, including CNAs, were involved in the situation and were misinformed about the resident's code status. The CNAs were told by LPNs that the resident was a DNR, which was later discovered to be incorrect. The failure to verify the resident's code status and initiate life-saving measures resulted in disciplinary actions for the involved staff, including termination for LPN #1. The facility's documentation also lacked an advance directive acknowledgment for the resident, further complicating the situation.
Removal Plan
- Staff were in-serviced on CPR status, DNR code status policy and procedures.
- Code status identification policy and procedures were included in all new hire packets, with in-person training.
- Code status identification was observed at each room/name plates on the memory care unit.
- The Activity Director was in-serviced regarding code status and CPR.
- LPN #3 was in-serviced regarding code status and CPR.
- Code status identification was observed at room/name plates in the long term care halls.
- RN #2 reviewed the in-service documentation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from eloping. The resident, who had diagnoses including dementia, diabetes mellitus, Parkinsonism, and anxiety, was identified as a moderate risk for elopement upon admission. Despite this, the resident exhibited combative behavior and expressed a desire to leave the facility, which was documented in the nurse's notes. On one occasion, the resident was found outside the front entrance but was redirected back inside. However, the facility did not consider this an elopement since the resident was still on the premises. On a subsequent occasion, the resident was found missing during routine rounds, and the facility initiated elopement procedures. The resident was eventually located at a nearby dealership parking lot and required medical care due to his condition. The facility's investigation revealed that the front door was unlocked, which allowed the resident to leave the premises. Staff interviews indicated that the resident had been verbalizing a desire to leave the facility and had been found outside the front door on a previous occasion. The facility's failure to lock the front door and adequately supervise the resident led to the elopement incident. The Administrator acknowledged that if the front door had been locked, it might have prevented the resident from eloping. The facility's investigation confirmed the need for immediate action to address the supervision and security lapses that allowed the resident to leave the premises unsupervised.
Removal Plan
- Resident #3 was placed on one-on-one supervision.
- The facility reassessed Resident #3's elopement risk and updated the care plan.
- The facility completed a headcount of all residents, reviewed all resident's elopement risk assessments and updated care plans.
- The elopement risk book kept at the nurse's station was reviewed and updated.
- The facility locked all the coded doors, changed the door codes to make them harder to figure out, and placed signage on all doors to not let residents out.
- Daily checks of doors were implemented.
- Staff members were in-serviced on elopement and keeping the doors locked.
- The facility conducted a root cause analysis exercise to determine the reason the elopement occurred.
Failure to Monitor and Administer Prescribed Antibiotic Therapy
Penalty
Summary
The facility failed to assess, monitor, and intervene for a resident experiencing a significant change in condition and did not ensure the resident received prescribed antibiotic therapy to treat pneumonia. On 03/08/24, the resident exhibited acute changes such as weakness, inability to stand or sit, irregular heart rate, low oxygen saturation, incontinence, and mental status decline. Despite notifying the MD, the resident was not sent to the ER, and no further MD notifications were documented as the resident's condition continued to deteriorate over the following days. On 03/19/24, the resident requested to be sent to the ER and was diagnosed with pneumonia, receiving an order for Augmentin. However, the facility failed to notify the resident's physician of the new order, did not submit the medication order to the pharmacy, and did not place the medication on the MAR. Consequently, there was no documentation that the prescribed antibiotic was ever ordered, received, or administered to the resident between 03/19/24 and 04/08/24. The resident's condition continued to decline, and on 04/08/24, they were sent to the ER with low blood pressure, labored breathing, erratic pulse, and altered mental status, leading to their hospital admission. The DON acknowledged that the resident had not been properly assessed, monitored, or received necessary interventions according to facility policy after experiencing a significant change in condition. Additionally, the resident did not receive the prescribed antibiotic therapy for pneumonia, as documented in the clinical records and MARs.
Removal Plan
- All Licensed RN/LPN staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All newly hired Licensed RN/LPN staff will be educated on how to recognize change in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All direct care nursing staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs and report to charge nurse immediately.
- DON/Designee will review all new hire packets to ensure all training is completed.
- DON/Designee will report any negative findings to the QAPI team.
- All licensed RN/LPN In-serviced on Facility Policy and Procedure properly assessing, monitoring, and intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- All licensed new hires will be educated on Facility Policy and Procedure on properly assessing, monitoring, intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- DON/designee will review all new hire packets to ensure all training is completed.
- DON/designee will report any negative findings to QAPI.
- DON/Designee will compare physician orders on all new admissions to MAR and verify all medications are on hand.
- Any staff that are on leave will be educated prior to being placed on the schedule.
- DON/ADON in-serviced on reviewing all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed.
- DON/ADON will review all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed. Any negative findings will be corrected immediately.
- All Licensed nurses educated on comparing new orders/hospital discharge orders with the MAR and updating MAR to reflect any new orders.
Failure to Provide Timely CPR to Unresponsive Resident
Penalty
Summary
The facility failed to ensure that a resident who had become unresponsive was immediately assessed by a licensed nurse and received cardio-pulmonary resuscitation (CPR) according to standards of practice. The resident, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, was documented as a full code. Despite this, the resident did not receive timely CPR when they became unresponsive after multiple falls while being walked to the dining room by an LPN. The LPN, along with other staff members, transferred the unresponsive resident to a wheelchair and then to their bed without performing an immediate assessment or initiating CPR. The LPN incorrectly believed the resident was a do-not-resuscitate (DNR) and did not perform CPR until much later, after being informed by the Director of Nursing (DON) that the resident was a full code. By the time CPR was initiated, it was performed improperly, with the resident in a bed without a backboard and compressions being too deep, as observed by the DON. The incident was captured on a facility video recording, which showed the resident falling multiple times and being transferred to a wheelchair by the LPN, a physical therapist (PT), and a certified medication aide (CMA). The video also recorded the LPN and other staff members standing over the resident without performing an assessment or initiating CPR. Witnesses, including CNAs and the PT, confirmed that the resident appeared unresponsive and had blue lips, indicating a lack of oxygen. Despite these signs, the LPN did not perform CPR immediately and instead moved the resident to their room, where they were placed in bed and left unattended for a period. Interviews with staff members revealed that the LPN had a mistaken belief about the resident's code status, which led to a delay in initiating CPR. The DON confirmed that the LPN did not follow facility policy during the incident and that the CPR performed was inadequate. The LPN's actions and inactions, including the failure to assess the resident immediately and the improper execution of CPR, contributed to the deficiency identified by the surveyors.
Removal Plan
- LPN #1 was terminated.
- The DON or designee educating all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident.
- RN shift supervisor given responsibility to direct/assign staff roles during code/initiation of code.
- A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted.
- DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy.
- DON or designee performed a Code Blue drill and was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held.
Failure to Prevent Significant Medication Errors
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to prevent significant medication errors for a resident. The resident was ordered Morphine 20mg/ml to be administered 0.5ml every four hours as needed. However, the Controlled Drug Receipt/Record/Disposition Form documented that an LPN administered additional doses of Morphine outside the prescribed schedule, including at 10:15 a.m., 2:30 p.m., and 3:00 p.m., per family request, without contacting the physician for orders for these additional doses. The Medication Administration Record (MAR) also showed discrepancies in the administration times and doses, with the LPN admitting to documenting the wrong date and failing to follow the physician's orders. The resident expired later that day at 4:13 p.m. without the LPN having contacted the physician for the additional doses administered. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. The facility's Medication Error policy and Guidelines for Physician Orders policy were not followed, as the LPN administered medications outside the prescribed time frames and without physician authorization. The LPN admitted to using a 10ml syringe to draw up an unknown amount of Morphine and administering it to the resident in an attempt to appease the family. The LPN also admitted to making hasty and inaccurate entries on the narcotic record to justify the discrepancies and ensure the oncoming nurse would take the cart keys. The DON and other staff members confirmed that the LPN had not followed physician orders and had administered Morphine outside the prescribed schedule, leading to the resident's death. The DON and other staff members expressed concerns about the LPN's actions, stating that the LPN was a danger to the residents due to their failure to follow physician orders and accurately document medication administration. The medical director described the LPN's actions as gross negligence, and the regional nurse consultant confirmed that the LPN had administered Morphine outside the prescribed schedule based on family requests. The facility's failure to ensure medications were administered as ordered resulted in significant medication errors and the resident's death.
Removal Plan
- Nurse #1 was immediately interviewed and suspended pending investigation following the discovery of the potential medication error, thus removing the potential to affect other residents.
- Nurse #1 was terminated after not showing up for her scheduled meeting, competency validation, and continued employment evaluation.
- Narcotic count sheets were audited to verify accurate count recorded and matching count of medications.
- Physician's Orders were validated to match the Medication Administration Record and administration times were verified to be within acceptable range.
- Licensure verification for licensed nurses and CMA's were completed.
- Licensed Nurses and CMA's were inserviced on medication administration of routine and as needed medication, following physician's orders, physician notification, change of condition, medication orders/requests, additional medication doses, adverse reactions, and new admission process.
- Phone calls with a verbal inservice will be given if any staff are on vacation or unable to come to the facility for an in-person inservice.
- Competency validations began for all licensed nurses and CMA's to be successfully completed prior to administering medication and/or providing care.
- Newly hired nurses and CMA's will be educated upon hire and competence validated prior to administering medications to any resident.
- An Ad-Hoc QAPI Meeting was held by the Administrator, the Interdisciplinary Team, and Medical Director to review and approve the Plan of Removal and Allegation of Compliance.
- Audit Tools were created to include monitoring of medication delivery including following physician's orders, narcotic count, and accuracy of count compared to actual medication.
- The QAPI Committee will review the audit tools and will determine compliance. Any concerns will have been addressed. If indicated, additional Action Plans will be recommended and/or written by the QAPI Committee.
- All Action Plans will be monitored by the Administrator to ensure substantial compliance.
Failure to Provide Safe Environment for Resident
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to provide a safe environment for Resident #1, who was found with her left arm caught in a bed rail that had fallen on it. The incident was documented on 01/03/24, and the resident was subsequently transferred to the ER on 01/04/24, where she was diagnosed with a closed fracture of the left distal humerus. Despite the injury, the resident was observed on 01/17/24 with two upper bed rails raised, indicating that no new interventions had been put in place to prevent further injury. The Director of Nursing (DON) acknowledged on 01/18/24 that no physician's orders or bed rail risk assessments had been completed for Resident #1. Additionally, there was no documentation that the risks and benefits of using bed rails had been discussed with the resident's representative, nor was there any signed consent obtained before the bed rails were put in use or upon the resident's return from the hospital. This lack of proper assessment and documentation contributed to the unsafe environment that led to the resident's injury. The facility's failure to identify and eliminate a known and foreseeable accident hazard was evident in the case of Resident #1, who had severe cognitive impairment, limited movement, and was dependent on others for all activities of daily living (ADLs). The absence of a bed rail risk assessment and the continued use of bed rails without proper authorization and safety measures directly led to the resident's injury, highlighting a significant deficiency in the facility's safety protocols and resident care practices.
Removal Plan
- All bedrails in the facility were lowered pending Pre-restraining assessment, restraint: side rail utilization assessment, consent from resident/family member for physical restraint and physicians order for the use of bedrails.
- Resident #1's bedrails were lowered, her bed was lowered to the lowest position and pillows were placed to maintain position for her protection.
- All residents or their families were educated on the pros and cons of bedrail restraints.
- Pre-restraining assessments were completed on all residents.
- Side rail utilization assessments were completed on five residents requesting bedrails.
- Consents were obtained verbally from Resident #1's guardian, unnamed resident #2's POA, and Resident #3, and consent forms were mailed to them.
- Physician's orders were obtained for the five residents that requested bedrails be utilized while in bed.
- Care plans have been updated for the residents requesting bedrails.
- The five residents that have requested bedrails will be reassessed and consents will be updated.
- Residents that have requested some type of bedrail will be visualized for safety and positioning every two hours and as needed while in bed when bedrail is being utilized.
- All bedrails in the facility that are not being used have been zip tied to prevent use when not authorized by staff and visitors without proper assessments, consents and orders.
- Staff have been educated on the facility policy for restraints: pre-restraining assessment, side rail utilization assessment, consent for side rail and physicians order for side rails.
- Staff were educated on making sure residents are safe and moved from faulty bed then reporting to maintenance log.
- Staff were in-serviced on procedure for reporting faulty bed to maintenance using identifying bed number along with room number and problem that has been identified to maintenance in the maintenance logbook.
- All beds were reassessed for proper working order.
- All beds will be assessed for proper working order utilizing a tracking log.
- The maintenance supervisor or designee will monitor the maintenance log for any beds that are not working properly.
- The Director of nurses or designee will assess all residents upon admission for restraints and consents will be obtained upon admission per facility restraint policy.
- The QAPI committee will review all new assessments and consents for new admissions.
- Care plans will be updated on admission.
- The QAPI committee will review all care plans for residents that have requested bedrails.
- The Maintenance Supervisor will address any bed or equipment issues with the QAPI committee.
- The Maintenance Supervisor will present bed tracking log to the QAPI committee.
Resident Elopement Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, which resulted in the resident being hospitalized for rhabdomyolysis, acute kidney injury, and a urinary tract infection. The resident, who had diagnoses including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and bladder cancer, was identified as having a low risk of elopement. However, on the day of the incident, the resident was last seen around noon and was not accounted for during the evening shift. Multiple staff members provided inconsistent accounts of when they last saw the resident, and it was noted that the resident was able to leave the facility through a door to the smoking area by using a door code. The resident was found the following day at a family member's house after having walked an estimated 20 miles without food or water. The facility's elopement policy required staff to promptly report missing residents and initiate a search, but it appears these procedures were not effectively followed. The incident report and employee statements indicate a lack of communication and coordination among staff, as well as a failure to conduct timely elopement risk assessments. The facility's administrator and DON were unaware of how the resident managed to leave the building and reach their family's house. The deficiency highlights a significant lapse in supervision and adherence to the facility's elopement policy, which ultimately led to the resident's hospitalization.
Removal Plan
- Elopement risk assessments conducted on all residents
- Signs posted on front door to alert visitors not to let anyone out
- All staff inserviced
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