Citations in Oklahoma
Statistics, citations 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
Medications Not Available for Ordered Administration: The facility failed to ensure ordered meds were available for administration for two residents. One resident’s MAR showed missed doses of Modafinil and Xalatan eye drops because the meds were not available, and another resident’s MAR/TAR showed missed doses of Cefdinir and ipratropium bromide-albuterol because the meds were not available or were on order. The DON stated the meds should have been available and administered as ordered.
Failure to perform hand hygiene and wear a gown during wound care: An LPN provided wound care to a resident with a wound and EBP orders while wearing gloves but not a gown, changed gloves without hand hygiene, and left the room without hand hygiene. The DON stated gown and gloves were required for wound care, and the LPN stated they had not received training on EBP and did not know which residents required them.
Incomplete discharge planning documentation and notification: The facility failed to ensure discharge plans were completed, reviewed with the resident, and copied to the resident and/or family for two residents. One resident with CHF, DM2, AKI, ESRD, and dialysis dependence had an incomplete discharge planning document, and another resident with a femur fracture, CAD, PVD, and hypersomnia had no documentation of discharge planning before discharge. The resident reported receiving medication instructions but not clear information about the discharge day or time, and the social services director and DON stated the required discharge planning documentation was not in the medical record.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
Unsecured Medication Cart Left Unattended: A medication cart was observed unlocked and unattended on the south hall, with no staff in sight. The ADON walked to the cart and left without locking it, and a CMA later left the cart unlocked while helping another resident. Facility policy required medication carts to be securely locked when out of the nurse's view, and the ADON stated anyone could have taken the medications from the cart.
Failure to supervise a resident at high risk for wandering led to an elopement event. The resident had dementia, delirium, and head injury, with moderate cognitive impairment and later documentation showing a high wandering risk. Nursing notes described the resident as confused, pacing, and easily redirected, and the resident exited the facility and was found at a fast food restaurant after crossing a busy four-lane highway.
Medications Not Available for Ordered Administration
Penalty
Summary
The facility failed to ensure medications were available for administration per physician orders for 2 of 6 sampled residents reviewed for medication administration. For Resident #11, physician orders dated 04/02/26 included Xalatan 0.005% eye drops, one drop in both eyes nightly at bedtime, and Modafinil 200 mg daily. The MAR for 04/02/26 through 04/12/26 showed Modafinil was held or missed from 04/03/26 through 04/11/26 because the medication was not available, and Xalatan eye drops were held or missed from 04/04/26 through 04/10/26 because the medication was not available. The Record of Admission form showed the resident was admitted with diagnoses including unspecified fracture of the left femur, muscle weakness, chronic pain, and hypersomnia. For Resident #7, physician orders dated 05/17/26 included Cefdinir 300 mg every 12 hours for three days and ipratropium bromide-albuterol inhalation every eight hours. The MAR showed Cefdinir was documented as held on 05/21/26 at 9:00 a.m. because the medication was not available. The TAR showed ipratropium bromide-albuterol was documented as held on 05/18/26 at 5:00 p.m., 05/19/26 at 5:00 p.m., 05/21/26 at 1:00 a.m., and 05/21/26 at 9:00 a.m. because the medication was on order. The Record of Admission form showed the resident was admitted with diagnoses including hypertension, saddle embolus of the pulmonary artery, and mild intermittent asthma. The policy titled Medication Ordering and Receiving from Pharmacy Provider stated timely delivery of new orders is required so medication administration is not delayed. On 05/28/26, the DON stated the medications were ordered for Residents #7 and #11 and were not documented as given per the medical record, and that the medications should have been available and administered.
Failure to Perform Hand Hygiene and Wear Gown During Wound Care
Penalty
Summary
The facility failed to perform hand hygiene and wear a gown during wound care for Resident #1, who had diagnoses including paroxysmal atrial fibrillation, an unstageable sacral pressure ulcer, pain, aphasia following cerebral infarction, and orders for topical wound treatments and enhanced barrier precautions. On 05/26/26 at 11:40 a.m., an LPN was observed providing wound care to the resident’s right calf, including removing the dressing, cleaning the wound, and applying gentamicin, Santyl, and calcium alginate, while wearing gloves but not a gown. The LPN was also observed changing gloves without performing hand hygiene before donning new gloves and did not perform hand hygiene before leaving the room. The facility policy stated hand hygiene should be performed before resident contact, before taking part in a medical or surgical procedure, after contact with contaminated articles, after resident contact, after contact with wounds, and after removal of gloves. The enhanced barrier precautions policy stated gown and gloves were required during high-contact care activities, including wound care. The DON stated residents on enhanced barrier precautions were identified by a colored name badge on the door and that staff should wear a gown and gloves during contact care for residents with wounds, peg tubes, or catheters. The LPN stated they had heard of enhanced barrier precautions but did not know which residents required them and had not received training or education about them.
Incomplete Discharge Planning Documentation and Notification
Penalty
Summary
The facility failed to ensure discharge plans were completed, reviewed with the resident, and a copy provided to the resident and/or family for 2 of 3 sampled residents reviewed for discharges. A facility policy titled Discharge Plan stated that, at a minimum, the post-discharge plan would include social services reviewing the plan with the resident and family before discharge and providing a copy to the resident, with another copy filed in the medical record. Resident #5 was admitted with diagnoses including acute systolic and diastolic heart failure, type 2 diabetes mellitus, acute kidney failure, end stage renal disease, and dependence on renal dialysis, and was later discharged from the facility. The discharge planning document for this resident was incomplete for goals, participating members, and discharge planning. Resident #11 was admitted with diagnoses including fracture of the left femur, atherosclerotic heart disease, peripheral vascular disease, and hypersomnia, and was later discharged from the facility. There was no documentation that discharge planning was provided before discharge. The resident stated they received medication instructions but were not clear on the discharge day or time until they were told they were ready to go home and needed someone to pick them up. The social services director stated there was not a care plan meeting or discharge planning meeting for this resident, and notes kept regarding planning and conversations were not in the medical record or provided to the resident or family. The DON stated the discharge planning form should have been completed by the interdisciplinary team and placed in the medical record, and they did not know whether a copy had been given to either resident or family because there was no documentation in the electronic medical record.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure a medication cart was supervised and locked for 1 of 2 medication carts observed. On 05/19/26 at 4:43 p.m., medication cart #1 on the south hall by the nurse's station was observed unlocked and unattended, with no staff in sight. At 4:44 p.m., the ADON walked to the unlocked cart and left without locking it. At 4:45 p.m., CMA #1 was observed leaving a resident's room on the north hall and going to medication cart #1, which remained unlocked and unattended while the CMA was away from it. The facility policy titled Security of Medication Cart, revised April 2007, stated that medication carts must be securely locked at all times when out of the nurse's view. CMA #1 stated the cart should have been locked and supervised at all times and acknowledged forgetting to lock it and leaving it unlocked while helping another resident. The ADON stated anyone could have taken the medications from the cart and that the cart was to be locked and supervised.
Failure to Supervise a Resident at High Risk for Wandering
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident who had a history of wandering and cognitive impairment. Resident #3 had diagnoses including dementia, delirium, and head injury, and an admission assessment showed a BIMS score of 11, indicating moderate cognitive impairment. A wandering risk scale dated 03/23/26 identified the resident as low risk for wandering, with no history of wandering noted at that time and no wandering interventions included in the care plan. Later, a wandering risk scale dated 04/22/26 identified the resident as high risk for wandering, noting a history of wandering and continued cognitive impairment. Nursing notes documented that the resident was pacing, confused, and easily redirected, and on 05/10/26 the resident exited the facility and was found at a fast food restaurant four blocks away after crossing a busy four-lane highway. An incident report stated a witness had seen the resident leave the facility earlier and later observed the resident at the restaurant, then called the facility to report it. A CMA stated the resident was pleasant, confused, and wandered often, but did not show exit-seeking behaviors before the elopement event.
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Compliance trends in Oklahoma
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Oklahoma
- Restricted access to controlled substances to licensed nurses only (K - F0755 - OK)
- Discontinued CMAs from receiving or administering controlled substances (K - F0755 - OK)
- Implemented end-of-shift dual-signature controlled-substance counts by two licensed nurses (K - F0755 - OK)
- Required narcotic deliveries to be verified against pharmacy delivery receipts and signed into controlled-drug count sheets at receipt (K - F0755 - OK)
- Required delivery receipts to be attached to the unit narcotic packet and routed to the DON by end of shift (K - F0755 - OK)
- Verified controlled-substance storage as double-locked and functional (K - F0755 - OK)
- Re-educated licensed nurses and CMAs on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations (K - F0755 - OK)
Failure to Reconcile and Account for Controlled Narcotics for Two Residents
Penalty
Summary
The facility failed to maintain an effective system for the receipt, disposition, and reconciliation of controlled narcotic medications, resulting in unaccounted controlled drugs for two residents. Facility policy required a system for receipt, storage, administration, counting, reconciliation, investigation of discrepancies, and destruction of all controlled substances, including verification by two authorized staff upon delivery and documentation of the initial count. However, for one resident with chronic pain, hypertension, and major depressive disorder, a pharmacy packing slip showed that 120 oxycodone/APAP tablets were delivered, but count sheets and medication cards for 90 tablets could not be located. The controlled drug count sheet for this resident showed only 30 tablets received and documented 19 administered doses that were not recorded on the MAR. For this same resident, the Medication Log of Receiving did not reflect the oxycodone/APAP delivery, and the MAR for the relevant months showed only three administered doses, while the resident reported they had not taken the medication because they did not like how it made them feel and that the last dose was about two months prior. A CMA reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident had only taken the first dose; this was reported to the administrator. Another CMA confirmed the issue was discovered during a cart count and that it was immediately reported to the administrator. Nursing staff, including an LPN, denied administering narcotics to this resident or signing the count sheet, and pharmacy staff confirmed the full quantity of 120 tablets had been delivered. For a second resident with chronic pain and major depressive disorder, a physician’s order prescribed hydrocodone/APAP three times daily, and a pharmacy packing slip showed 90 tablets were delivered. The Medication Log of Receiving did not show that this delivery was logged, and a count sheet and medication card for 30 tablets were missing. When the resident’s controlled drug count sheets and packing slips for several months were reconciled with the ADON, 30 hydrocodone/APAP tablets were found to be unaccounted for, and the ADON stated there should have been three count sheets for one month but only two were located. The administrator acknowledged the facility had been without a full-time DON for an extended period during the time these discrepancies occurred, and staff interviews indicated that reconciliation practices were limited to matching the count sheet and card, with RNs usually responsible for medication reconciliation.
Removal Plan
- The administrator and DON were in-serviced by the corporate administrator regarding the facility's controlled-substance reconciliation system, including mandatory reporting and record keeping requirements.
- All narcotic deliveries received would be verified against the pharmacy delivery receipt and signed into the controlled drug count sheets by a licensed nurse at the time of receipt.
- Delivery receipts would be attached to the unit's narcotic packet and routed to the DON by end of shift.
- The nurse consultant completed a full-scope audit of all units and verified medication availability for all residents with active orders.
- Access to controlled substances was restricted to licensed nurses only.
- CMAs would no longer receive or administer controlled substances.
- Medication storage for controlled substances was verified as double-locked and functional.
- End of shift dual signature counts by two licensed nurses were implemented.
- All licensed nurses and CMAs were re-educated by the ADON and LPN #4 on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Enforce Smoking Policy and Supervise Oxygen-Dependent Smoker
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards related to smoking, resulting in a resident smoking in their room while wearing oxygen and sustaining facial burns. The facility had a written smoking policy stating that residents would not be allowed to have cigarettes, matches, or lighters in their possession or in their rooms, and that no smoking was permitted in resident rooms or hallways. Despite this, the resident was able to obtain and use smoking materials in their room. Staff, including the administrator and DON, acknowledged that housekeeping had previously found ashes on the resident’s toilet seat and that the resident had been reported to have smoked in their room multiple times over a two‑month period. The resident involved had diagnoses including COPD, lung cancer of the right lower lobe, respiratory failure, anxiety, depression, and paranoid schizophrenia, and used oxygen. Assessments showed the resident was cognitively intact with a BIMS score of 15 and was identified as a smoker. A smoking assessment documented on 11/12/25 indicated the resident could safely smoke with minimal supervision, and a subsequent assessment on 02/12/26 noted the resident had been observed hiding a cigarette in their pocket to smoke later, yet still concluded they could safely smoke with minimal supervision. A nurse progress note on 02/12/26 recorded that staff had observed the resident placing a cigarette in their jacket pocket and had educated the resident on the dangers of smoking while wearing oxygen. Despite these documented concerns and prior observations of unsafe smoking behavior, the resident continued to access smoking materials and smoke in their room. A nurse progress note dated 03/03/26 recorded that the resident had smoked in their room the night before while wearing oxygen, resulting in burns to the resident’s face. On observation, the resident was noted to have singed mustache hair and a wound near the upper lip. The administrator reported that the maintenance director later found a lighter under the resident’s bed and that it had been reported the resident had smoked in their room six times between early January and early March. Staff interviews confirmed that residents were not supposed to have smoking materials in their possession and were to be supervised while smoking, but also revealed that there was no guarantee that all lighters and cigarettes had been removed from the resident’s room.
Removal Plan
- Notify Medical Director
- Notify resident #26 hospice provider of IJ and coordinate care
- Complete a new Smoking Assessment for all smokers
- Review and revise the smoking policy with the resident and resident council (with agreement/approval) to include checking for any smoking material at the end of each smoke break; update the policy to include observation of smoking residents to ensure smoking material (e.g., cigarette butts) is distinguished and disposed of and the lighter is returned at the end of smoking times; implement a checklist to ensure each resident has complied; staff supervising smoke breaks will keep the smoking materials container in their possession with only one lighter available and will give each resident only one cigarette at a time; all smoking materials brought in by friends/family will be checked in at the nurse's station
- Post the reviewed/revised smoking policy with resident council approval at the nurses' station and by the exit leading to the smoking area
- Have smoking residents sign the revised smoking policy acknowledging the policy
- Administrator to in-service staff on the revised smoking policy
- Regional supervisor to in-service Administrator/DON on ODHS Form 283 and completing it with adequate supervision of residents and follow-up for accidents/incidents related to smoking and charting interventions and follow-up care
- Update the care plan for resident #26
- Review all smoking residents' care plans and revise as needed for adequate supervision/intervention to prevent accidents/injury and ensure follow-up if an occurrence happens
- Move resident #26 to a room closer to the nurse's station
- Educate resident #26 on hazards of smoking in the room and potential harm due to combustion with oxygen; have resident sign education sheet and upload to the resident EHR under resident documents
- Send all ODHS Form 283 reports to a Regional Supervisor for review for completeness and adequate intervention to prevent reoccurrence and ensure follow-up
- Initiate QAPI for the IJ and monitor implementation of the above interventions for removal of IJ
Fatal Medication Error Due to Failure to Correctly Identify Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically failing to correctly identify a resident before administering medications. A cognitively impaired resident with a history of atherosclerotic heart disease, hyperlipidemia, hypertension, and traumatic brain injury was admitted with orders that included amlodipine 5 mg for hypertension, to be held if systolic blood pressure was less than 115 or heart rate was less than 50. A quarterly assessment documented significantly impaired cognition with a brief mental illness score of 03, use of multiple psychotropic and other medications, and no indication that the resident rejected care. Vital signs taken the morning of the incident showed a blood pressure of 147/76 and pulse of 83 beats per minute. On the morning in question, a CMA administered medications intended for the resident’s roommate to this resident after asking the resident if they were the roommate and accepting the resident’s incorrect verbal confirmation as sufficient identification. The CMA reported being unfamiliar with the residents and relied on the resident’s verbal response rather than using other identification methods such as the photo in the health record, despite the resident’s known cognitive and hearing impairments. As a result, the resident did not receive 11 medications that were prescribed for them and instead received multiple medications prescribed for the roommate, including amlodipine 10 mg, lisinopril 40 mg, and labetalol 300 mg, all ordered with parameters to hold for low systolic blood pressure and/or low heart rate. Shortly after the medication error, nursing notes documented that the resident became diaphoretic, lethargic, pale, cyanotic around the lips, with labored breathing and unresponsiveness. EMS records indicated the facility reported that the resident had been given amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride in error, and EMS found the resident lethargic with sinus bradycardia, shallow respirations, and initiated cardiac arrest protocol. Hospital records showed the resident was treated for having been administered the wrong medications and was diagnosed with hypotension, bradycardia, and asystole, and was pronounced expired later that morning. The medical director stated that labetalol 300 mg administered in error could have caused the resident to expire and that labetalol, amlodipine, and lisinopril all lower blood pressure, and further noted that epinephrine administered by EMS in the presence of labetalol could have caused an acute cardiac event. The resident’s representative stated the resident expired as a result of the medication administration error.
Removal Plan
- Conducted a QAPI meeting where the IDT reviewed the facility’s medication administration policies and procedures to ensure they would keep residents safe
- Provided in-service education by the DON and ADON for all staff administering medications covering medication administration policies and procedures, including correct resident identification during medication pass
- Implemented bi-weekly visual audits of staff administering medications to ensure compliance with medication administration policies and procedures
- Observed staff administering medications to verify they were identifying the correct resident during medication pass
- Verified medication aide certifications
- Completed medication aide skills check-offs
- Reviewed nursing licenses
- Suspended a medication aide
- Observed and interviewed medication aides and nursing staff across multiple shifts to confirm they had the skills and knowledge to correctly identify residents during medication pass and administer medications as prescribed
Failure to Supervise Cognitively Impaired Resident Leading to Elopement and Fatal Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known cognitive impairment and wandering risk. A quarterly assessment documented that the resident had moderate cognitive impairment with a BIMS score of 12, and the face sheet listed diagnoses including dementia, diabetes, and psychosis. The resident’s care plan identified the resident as being at risk for wandering. The administrator later stated that this resident had left the facility property approximately three times prior to the incident under investigation. The administrator also stated the facility did not have an alert system and had no policy regarding wandering or elopement. On the day of the incident, nursing documentation showed that at approximately 8:00 p.m. the resident insisted on leaving the facility. A CNA attempted twice to redirect the resident due to it being dark outside, and the nurse educated the resident about the safety concerns of walking in the dark while wearing dark clothing. The resident became agitated, cursed at staff, and then signed themself out of the facility. The nurse attempted to contact the resident’s family by phone, leaving voicemails and receiving no answer. CNA #2 reported seeing the resident sign out, telling the resident it was not a good idea, and then following the resident down the street for an undetermined distance before returning to the facility to care for other residents and informing the nurse. Subsequently, a police department case report documented that the resident was struck by a car, rolled onto the hood, and struck the windshield. An EMS run report showed that CPR was initiated by EMS and a police officer, an automated chest compression device was applied, and the resident was later pronounced deceased at the hospital. Surveyors determined that the facility failed to ensure adequate supervision to prevent elopement for this resident, despite the resident’s known wandering risk and prior episodes of leaving the property. The administrator identified two residents as being at risk for elopement at the time of the survey, and the survey findings concluded that the facility failed to provide adequate supervision to prevent elopements for one of three sampled residents reviewed for accident hazards.
Removal Plan
- Perform updated wandering risk assessments for all residents.
- Relocate any new admission or resident who develops wandering behavior to a facility with wander guard and secured doors or to the resident’s chosen home setting.
- Provide one-to-one supervision for any resident exhibiting wandering behavior until the physician assesses and the family and facility determine a plan.
- If a resident elopes and does not comply with staff direction, call 911 and the family immediately and keep staff with the resident.
- Develop and update individualized care plans for all residents, including interventions for wandering risk.
- Secure facility doors so staff must assist anyone entering or exiting.
- Require family and resident to sign a sign-out form when leaving the facility.
- Educate all staff on the sign-out process and related changes.
- If a resident leaves without signing out, call 911 and the family immediately.
- Change door access codes.
- Post signage instructing visitors to call the facility if no staff are present at the front entrance.
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