Citations in South Dakota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in South Dakota.
Statistics for South Dakota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in South Dakota
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to stop new ulcers from developing.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
An LPN administered an incorrect dose of diclofenac sodium gel by failing to use the manufacturer's dosing card and also crushed and administered a delayed-release omeprazole tablet to a resident, despite facility policy and manufacturer instructions prohibiting this. These actions resulted in a medication error rate of 6.9%.
Surveyors found that kitchen staff did not follow proper hand hygiene procedures, specifically failing to use a paper towel to turn off the faucet after washing hands, as required by facility policy. The kitchen and food storage areas were not maintained in a clean condition, with dust and buildup observed on equipment and surfaces. Additionally, food items in the dining room refrigerator were improperly labeled and stored, with some items undated, spoiled, or moldy, and not discarded as required by policy.
Staff did not consistently follow infection control protocols, including failure to wear required PPE when entering rooms under Enhanced Droplet Precautions, inadequate hand hygiene practices after glove removal and before resident care, and improper cleaning and disinfection of a shared glucometer used for multiple residents. Facility policy requiring individual, labeled glucometers for each resident was not followed, and staff did not have necessary cleaning supplies readily available.
Multiple residents using oxygen and CPAP equipment did not have their respiratory devices cleaned, replaced, or stored according to facility policy and manufacturer instructions. Observations showed dusty concentrators, undated and improperly stored nasal cannulas, and missing documentation for scheduled cleaning and replacement. Staff interviews revealed confusion about responsibilities, and facility records confirmed inconsistent scheduling and documentation of required maintenance tasks.
A resident's advance directive wishes were not accurately identified or documented after returning from a hospital stay, resulting in conflicting code status information between the EMR and paper chart. The EMR was updated to 'Intubate Only' without discussion with the resident, despite signed DNR documents and a care plan indicating DNR status. Staff confirmed they would follow the highest level of care listed, which did not reflect the resident's wishes.
An LPN left a resident's EMR information visible and unsecured on a medication cart computer while away administering medications, allowing staff and residents to pass by and view the protected health information. The DON confirmed that the system has a lock screen feature and staff are expected to use it, in accordance with the facility's HIPAA policy.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Medication Error Rate Exceeds 5% Due to Improper Administration and Crushing of Medications
Penalty
Summary
A medication error rate of 6.9% was identified during observation of medication administration by an LPN. The LPN dispensed an unknown amount of diclofenac sodium 1% gel for a resident's arthritis pain and inflammation, failing to use the manufacturer's enclosed dosing card as required. The LPN was unaware of the measuring device included in the medication packaging and could not confirm the correct dose, resulting in improper administration. The medication administration record (MAR) specified a two-gram dose, but the LPN guessed the amount and only discovered the dosing card after the error was pointed out. Additionally, the same LPN crushed and administered an extended-release medication, omeprazole 20mg delayed-release oral tablet, to another resident who required medications to be crushed. The MAR did not indicate that these medications should be crushed, and the LPN was unaware that omeprazole was a delayed-release formulation, only realizing the error after reviewing the medication label. The facility's policy and the manufacturer's recommendations both specify that extended-release or delayed-release medications should not be crushed and that medications must be administered as prescribed and in accordance with manufacturer specifications.
Failure to Follow Food Safety and Hand Hygiene Protocols
Penalty
Summary
Surveyors observed multiple failures to follow standard food safety and hand hygiene practices in the facility's kitchen and dining areas. Three of five kitchen staff, including a cook and two dietary aides, did not use a paper towel to turn off the faucet after handwashing, contrary to posted instructions and facility policy. This improper handwashing technique was observed during six of nine handwashing events. The dietary manager and infection preventionist confirmed that the policy requires using a paper towel to turn off the faucet to prevent recontamination. Additionally, the kitchen environment was not maintained in a clean condition, with a dusty power cord hanging above clean dishware, uncovered serving utensils, and dust and buildup on ventilation filters and air vents near food preparation and dishwashing areas. In the dining room refrigerator, food items belonging to three residents were found improperly stored. Several containers were labeled with resident names but lacked dates, and one container emitted a foul odor when opened. Another bag of vegetables was visibly moldy and undated. The activities director, responsible for managing the refrigerator, acknowledged that food without dates should have been discarded during the last cleaning, as per facility policy, which requires all food brought in from outside to be labeled with the date and discarded after three to five days. The cleaning log indicated the refrigerator had not been deep cleaned since the previous week, and undated or expired food was not removed as required.
Infection Control Failures in PPE Use, Hand Hygiene, and Glucometer Disinfection
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several observed instances. A guest services aide entered two residents' rooms, both under Enhanced Droplet Precautions, without donning the required personal protective equipment (PPE) such as gown, gloves, and eye protection, as indicated by signage. The aide only wore a face mask and did not change it between rooms, although she performed hand hygiene upon exiting each room. The aide acknowledged that PPE was expected in these rooms. A certified nurse aide (CNA) was observed removing unclean gloves after providing personal care to a resident and then immediately putting on a new pair of gloves without performing hand hygiene in between. The CNA confirmed that hand hygiene should have been performed after glove removal and before donning new gloves. Additionally, an LPN was seen placing a straw into a resident's water cup with bare, unwashed hands, and admitted that she should have either washed her hands or worn gloves before handling the straw. There was also a failure to follow manufacturer and facility policy regarding the cleaning and disinfection of a shared blood glucose monitor (glucometer). An LPN used an unlabeled glucometer for multiple residents, did not have cleaning wipes readily available, and did not follow the manufacturer's instructions for cleaning and disinfecting the device between uses. The facility's policy required individual glucometers for each resident, properly labeled and stored, but this was not followed, as confirmed by the Director of Nursing.
Failure to Clean and Store Respiratory Equipment per Policy
Penalty
Summary
The facility failed to ensure that respiratory treatment equipment, including oxygen concentrators, nasal cannulas, and CPAP machines, was cleaned and stored according to manufacturer instructions and facility policy for multiple residents. Observations revealed that several oxygen concentrators had visible dust and debris on their filters and exteriors, with one concentrator labeled with another person's name. Nasal cannulas were found undated, improperly stored—such as hanging over wheelchair wheels or lying on the floor—and in some cases, not replaced according to the facility's weekly schedule. Documentation in the treatment administration records (TAR) was inconsistent or missing for scheduled cleaning and replacement tasks. Residents using oxygen and CPAP equipment had varying degrees of cognitive function and medical needs, including chronic respiratory failure, hypoxia, and sleep apnea. Interviews with residents indicated a lack of awareness regarding the maintenance of their respiratory equipment. For example, one resident with severe cognitive impairment could not confirm if his CPAP mask and tubing or oxygen concentrator were cleaned, while another resident with intact cognition was unaware of any replacement or cleaning of her equipment. The CPAP mask and tubing for one resident were left assembled and not cleaned or scheduled for cleaning as required. Staff interviews revealed confusion and inconsistency regarding responsibilities for cleaning and maintaining respiratory equipment. Certified medication aides and LPNs provided differing accounts of who was responsible for cleaning concentrator filters, with some believing it was a nursing duty and others attributing it to maintenance or an outside oxygen company. The infection preventionist and DON confirmed that cleaning and replacement tasks were to be documented in the TAR, but acknowledged that documentation was missing or not scheduled for some residents. Facility policies required weekly cleaning and replacement of equipment, proper storage of nasal cannulas, and documentation of these tasks, but these procedures were not consistently followed.
Failure to Accurately Document and Confirm Advance Directive After Hospitalization
Penalty
Summary
A deficiency occurred when a resident's advance directive wishes were not accurately identified and documented after returning from a hospital stay. The resident's electronic medical record (EMR) listed his code status as 'Intubate Only,' while two signed Do Not Resuscitate (DNR) documents were present in both his EMR and paper chart, each signed by the resident, a provider, and a facility agent. The resident's care plan also indicated DNR status, and during an interview, the resident confirmed he believed his code status was DNR and expressed that he did not want to be intubated again after a previous experience. A licensed practical nurse (LPN) confirmed the discrepancy between the paper chart (DNR) and the EMR (Intubate Only), stating she would follow the highest level of care listed, which was 'Intubate Only.' The nurse supervisor updated the EMR to 'Intubate Only' after the resident returned from the hospital, based on a change observed during the hospital stay, but did not discuss this change with the resident. The director of nursing (DON) stated that any code status change after hospitalization should be confirmed with the resident, and that code status is reviewed at care conferences. The failure to confirm and accurately document the resident's code status led to the deficiency.
Failure to Secure Resident PHI on Unattended EMR Screen
Penalty
Summary
A licensed practical nurse (LPN) failed to secure a resident's protected health information (PHI) by leaving the electronic medical record (EMR) screen unlocked and visible on the medication cart while administering medications in the west hall. During this time, multiple staff members and residents walked past the unlocked screen, which displayed the resident's EMR information. The LPN acknowledged that the computer screen should have been locked when unattended. The director of nursing (DON) confirmed that the facility's EMR system includes a lock screen feature and that staff are expected to use it whenever they step away from the computer. Review of the facility's HIPAA policy further emphasized the requirement to log off computers when not in use and to protect PHI from unauthorized access. The incident constituted a breach of the facility's policy and federal HIPAA regulations regarding the privacy and security of resident information.
Some of the Latest Corrective Actions taken by Facilities in South Dakota
- The Dietary Manager educated all dietary staff on proper sink usage, water temperatures, sanitizer temperatures, and the importance of correct documentation and corrective actions when temperatures are outside requirements. ServSafe certification was pursued for key staff members, and new logs were implemented to ensure compliance with sanitation standards (L - F0812 - SD) .
- All expired test strips were removed, and new, non-expired strips were placed for use. Disposable dining ware was used temporarily until the dishwasher was functioning correctly. Staff received education on procedures for a non-working dishwasher and the importance of using non-expired test strips. Monitoring systems were established to track the expiration dates of test strips and ensure ongoing compliance (J - F0812 - SD) .
- Dietary staff were instructed to use paper plates and to wash all non-disposable items in the three-compartment sink until the dishwasher was repaired. A booster water heater was arranged to be installed to achieve the required dishwasher temperatures. New policies and temperature charts were implemented, and staff received mandatory education on the updated procedures (J - F0812 - SD) .
Failure to Maintain Proper Water Temperatures in Kitchen
Penalty
Summary
The provider failed to maintain the required water temperatures in the three-compartment sink in the kitchen, which increased the potential risk of foodborne illnesses for the residents. Observations revealed that the wash water temperature was consistently documented as 90 degrees Fahrenheit or lower, contrary to the required 110 degrees Fahrenheit. Additionally, the sanitizer water temperature was not maintained at the required 75 degrees Fahrenheit. Interviews with kitchen staff, including a cook and the dietary supervisor, indicated a lack of awareness and understanding of the correct temperature requirements. The dietary supervisor admitted to not knowing the expected wash water temperature and only reviewed logs to ensure documentation was completed, not to verify if the data was within expected parameters. A review of the August 2024 Three-Compartment Sink Log showed discrepancies, with wash water temperatures either exceedingly high or low, and no wash water temperatures documented for the entire month. The sanitizer water temperature was often recorded in the wrong column, and many recorded PPMs were below the expected range. The deficiency was identified as an immediate jeopardy situation, requiring immediate corrective action. The provider's failure to adhere to the Food and Drug Administration's recommendations and their own policy for maintaining proper water temperatures in the kitchen's three-compartment sink posed a significant risk to the health and safety of the residents receiving meals prepared in the facility.
Removal Plan
- DM educated all dietary staff on the 3 sink method, 3 compartment sink order, 3 compartment sink steps, water temperature in a 3 compartment sink, sanitizer temp, and when it is essential to clean and sanitize a utensil, sanitizer per manufacturer recommendations that include submerging for at least 1 minute.
- Education to dietary staff on compartment sink log requirements of testing temps and sanitizer ppm, including action required if temps are not within the requirements.
- DM, primary dayshift cook, primary evening cook, are enrolled in ServSafe Certification.
- All new dietary staff will receive ServSafe certification.
- A new log was created by DM to record wash, rinse, sanitizer water temperatures, and sanitizer ppm with each use, including what to do if temps or ppm are outside of parameters.
- LNHA provided education to DM on the policy and procedure manual, including 3 compartment sink method regulations, job description of the dietary manager including adherence to policies and ensure that sanitary regulations are followed by the entire department.
- Education provided on supervisory roles including ensuring the department adheres to State and Federal regulations, and assuming the authority, responsibility and accountability to carry out the duties of the dietary department, monitor use of equipment and chemicals, and ensuring required documentation is completed and appropriate per regulations.
- Education included reporting to LNHA any areas of concern within the dietary department, equipment, and chemicals.
- Dietary manager will complete ServSafe certification.
Inadequate COVID-19 Management and Infection Control
Penalty
Summary
The facility failed to manage COVID-19 cases effectively among 12 sampled residents, leading to improper precautions and further transmission of the disease. Observations revealed that residents who tested positive for COVID-19 were not isolated properly, with some negative residents remaining in the same room as their positive roommates. Staff were observed not following proper protocols for personal protective equipment (PPE) usage, such as not performing hand hygiene before and after glove use, and not changing N95 masks between rooms. Additionally, there were instances where staff did not wear PPE correctly, such as not securing N95 masks properly or wearing gowns outside of isolation rooms. The facility's records showed a lack of documentation regarding informing residents or their responsible parties about the risks of staying in the same room with COVID-19-positive roommates. Interviews with the Director of Nursing (DON) indicated that while there was an expectation to inform residents and document such communications, this was not consistently done. The facility's COVID-19 outbreak policy required placing residents with confirmed infections in single-person rooms when possible, but this was not adhered to, as evidenced by multiple residents remaining in shared rooms despite positive test results. Further deficiencies were noted in the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds. Observations showed that staff did not consistently use gowns, gloves, or eye protection when providing care to these residents, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to EBP protocols, with some staff unable to locate necessary PPE or unaware of the requirements for its use. This lack of compliance with infection control measures contributed to the facility's failure to prevent the spread of infections effectively.
Removal Plan
- All COVID-positive residents were moved in with other COVID-positive residents. All negative residents are grouped with well residents with no signs or symptoms of COVID. Other negative residents with known exposure, including resident #6, #38, and resident #8, are in the presumptive area with other presumptive residents.
- Staff have been educated on the importance of keeping all positive residents on isolation for 10 days. Staff are to redirect if they want to come out of their room.
- Staff education was completed by the DON and RN Nurse Specialist to ensure all staff who are currently working and are providing care to positive and presumptive residents knew how to properly DONN and DOFF PPE. PPE is put on prior to entering positive and presumptive rooms. This includes removing the gloves and gown inside the room and performing hand hygiene. The removal of the eye protection and mask happens outside the room. Masks and eye protection are discarded. Hand hygiene is performed again. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on properly wearing an N95 mask. All those not on shift will be educated prior to them coming on shift.
- All staff currently on shift were educated on proper hand hygiene after DOFFING PPE prior to assisting another resident. All those not on shift will be educated prior to them coming on shift.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Deficiency in Diabetic Care and Physician Notification
Penalty
Summary
The provider failed to ensure proper care and services for diabetic residents, specifically in monitoring blood sugar levels and notifying physicians when levels were outside the normal range. This deficiency affected four out of seven diabetic residents, leading to instances where blood sugar levels were not managed according to accepted clinical standards. Interviews and record reviews revealed that interventions and timely follow-ups were inconsistently documented, contributing to the deficiency. Resident 38, who has type 1 diabetes mellitus and other health conditions, experienced fluctuating blood sugar levels. On multiple occasions, her blood sugar dropped to dangerously low levels, yet there was no documentation of interventions or physician notifications. Similarly, resident 22, with type 2 diabetes and other serious health issues, had several high blood sugar readings without any record of physician notification. Resident 3, also with type 2 diabetes, had high blood sugar levels recorded without any documented physician contact. Resident 20, who is severely cognitively impaired, had high blood sugar levels without physician notification as well. The facility lacked a written policy on hypoglycemia management or diabetic care, relying instead on standing orders that were not reviewed by the current DON. Interviews with staff, including the ADON, revealed inconsistencies in the process for managing low or high blood sugar levels, with some staff unsure of the facility's policy. The deficiency was further highlighted by the lack of documentation of physician notifications for numerous blood sugar readings outside the normal range.
Removal Plan
- Diabetic residents #3, #20, #22, and #38 who receive insulin will be managed with the glycemic management protocol given by the medical directors' guidelines.
- Nurses (RN and LPN) as well as medication aides have been educated on hypoglycemia and hyperglycemia protocols.
- Nurses are to contact each individual residents' provider in event of a low or high blood sugar reading.
- Nurses were educated to document interventions for low or high blood sugar within the resident's EMR.
- Nurses have been educated on the importance of following each individual resident's guidelines given by the resident's medical provider to properly manage diabetes.
- Nursing staff education was completed by the DON and ADON to ensure those who are currently working are providing appropriate glycemic care and the steps to follow in the event of a low or high blood sugar reading.
- Glycemic management protocol instructs that the nurse on duty will contact the residents' provider during clinical hours or their hospital on-call provider after business hours.
- All nurses and medication aides not on shift will be educated prior to them coming on shift.
- All nurses and medications aides were educated on glycemic management protocols.
- Any concerns will be reported to the charge nurse, director of nursing, infection preventionist, and/or administrator immediately and addressed in facility QAPI.
Failure to Ensure Proper Sanitation Levels in Kitchen
Penalty
Summary
The provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. This deficiency was identified through observations, interviews, and record reviews. The survey revealed that the dishwasher's chemical sanitation was not functioning, and staff were not aware of any process to follow when this occurred. Additionally, staff could not accurately verify the chemical sanitation level of the dishwasher due to the use of expired test strips. During the survey, it was observed that the sanitizing testing strips located by the three-compartment sink had expired. Interviews with dietary staff confirmed that these expired strips were being used to test the sanitizing solution, which was not at the correct parts per million (PPM) for effective sanitization. The Nutrition and Food Services Supervisor confirmed that the test strips were outdated and that there were no other test strips available for use. Furthermore, the dishwasher sanitizer was tested and found to be insufficient, with a reading of 10 ppm instead of the required 50 ppm. The deficiency was further compounded by the lack of awareness among staff regarding the expiration of test strips and the proper procedures to follow when the dishwasher was not functioning correctly. The provider's policies and procedures for sanitizing food contact surfaces and warewashing were not effectively implemented, as evidenced by the expired test strips and the inadequate sanitizing solution levels. This failure increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents.
Removal Plan
- Provide dishwasher manufacturer manual and disinfectant information to support instructions are being followed and appropriate sanitation is occurring.
- Use disposable paper plates, cups, and silverware until dishwasher is running appropriately.
- Place new non-expired strips in for the 3 comp sink.
- Remove all expired strips in kitchen.
- Wash all dishes in the 3-comp sink until dishwasher is fixed to verify levels.
- Implement the use of a Monitoring Use of Ecolab disinfectant Test Strips form for staff to sign off on expiration date of a cartridge when replaced and label in the cartridge holder on the wall.
- Complete education with all dietary staff on proper procedure for non-working dishwasher and education on non-expired test strips with return demonstration.
- Educate all staff via PCC Communications that kitchen staff must ensure all chemical test strips are not expired for the dishwasher and the 3 comp sink.
- Add to the TELS Service Provider a task for Director of Environmental Services to monitor weekly if a cartridge is near expiration and needs replacement.
- Contact EcoLab to fix dishwasher. In the meantime, try a new bucket of Ultra San Ecolab 5 gallon liquid sanitizer in the dishwasher and retest.
Dishwasher Temperature Noncompliance
Penalty
Summary
The provider failed to maintain the dishwasher wash cycle temperature at a minimum of 120 degrees Fahrenheit as required by the manufacturer's manual. Observations and interviews revealed that the dishwasher's wash cycle temperatures were consistently below the required threshold, with recorded temperatures ranging from 100 to 115 degrees Fahrenheit over several days. There were also numerous instances where wash, rinse, and chemical sanitation level checks were missing. The facility's dishwasher was serviced monthly by a vendor, but the issue persisted, and the administrator was not notified of the low-temperature readings. Interviews with dietary staff confirmed that the dishwasher's external thermometer readings matched those of a thermometer run through the dishwasher, both indicating temperatures below the required 120 degrees Fahrenheit. The dietary aide acknowledged that the wash temperature should be 120 degrees Fahrenheit. Despite the lack of gastrointestinal illness reported in the past three months, the administrator expected staff to report low-temperature readings, which did not occur. A review of the ECOLAB service report and the facility's cleaning policy revealed discrepancies in temperature requirements. The ECOLAB report noted a wash temperature of 100 degrees Fahrenheit and advised monitoring for compliance. The facility's policy inaccurately stated that the dishwasher, a chemical sanitizing machine, required temperatures between 90 and 110 degrees Fahrenheit, conflicting with the manufacturer's specification of a minimum of 120 degrees Fahrenheit.
Removal Plan
- Dietary staff were instructed to use paper plates and bowls and to use the three-compartment sink for cleaning and sanitizing of all utensils/pots/pans, etc. that are not disposable.
- Administrator met with Dietary staff and reviewed the policy and procedure on the use of the three-compartment sink as well as instructions located above the three-sink area.
- Administrator spoke with the representative from ECO Lab concerning this noncompliance. Recommendation to install a booster water heater to the current dishwasher unit.
- Administrator spoke with [Name] from [Name] Heating and Cooling and arranged for a service call to complete wiring for the installation of the booster water heater.
- [Name] Heating and Cooling presented to facility. Conversation was held with [Name] from [Name] Heating and Cooling and [Name] from ECO Lab via phone. [Name] from ECO Lab and [Name] from [Name] Heating and Cooling will be installing the booster water heater.
- Administrator completed and implemented new Dishwasher Temperature Policy and Low-Temperature Dishwasher Chart.
- Dietary Staff mandatory education will be held to review the Dishwasher Temperature Policy and Procedure as well as the Low-Temperature Dishwasher Chart.
- Daily audits to ensure compliance with the dishwasher temperature will be completed by this Administrator and will report findings to the QAPI Committee. Following continuous compliance, daily audits will change to weekly audits. The continuation of audits will be reviewed monthly during QAPI Committee meetings.
Inadequate Supervision Leads to Resident Self-Harm
Penalty
Summary
The provider failed to provide adequate supervision for a resident to prevent actions of self-harm. The resident was observed in his room with multiple open areas on his bilateral lower legs, some of which were actively bleeding, while holding a sharp instrument. Staff interviews revealed that they were aware the resident had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. The resident's care plan allowed him to have sharps in his possession to remove perceived bugs from his skin. The resident had a history of picking at his skin and cutting himself, believing there were bugs under his skin. He had been seen by a behavioral counselor due to suicidal ideations and hallucinations. Despite this, the resident was allowed to keep sharps in his room, and staff were aware of his behavior but did not adequately supervise or intervene to prevent self-harm. Interviews with staff indicated that the resident was independent, allowed to leave the premises, and would purchase items, including sharps, from a store. The resident's care plan documented his behavioral symptoms, including cutting and picking at his skin, and allowed him to keep sharps in his room. The care plan noted that the resident declined to follow physician-recommended advice and would not allow nurses to care for his open areas. Staff were aware of the resident's behavior and the presence of sharps in his room, but there was no inventory or tracking of the sharps, and the resident's wounds were not regularly documented or treated by nursing staff.
Removal Plan
- All sharps have been removed from Resident 20's room.
- Psychiatry, primary care provider and counselor have been notified for guidance in managing any adverse behavioral changes.
- Resident 20 has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds.
- Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed, one-hour check while in the facility for behaviors given resident psychiatric history then re-evaluate.
- Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response.
- Director of nursing spoke to Resident 20 about dressing changes.
- Resident agreed to let nursing staff change dressing twice a day.
- Nursing staff will monitor for any signs of infection during dressing changes and notify the physician if any noticed. These will be documented on Resident 20's treatment.
- Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet.
- Resident was informed that he would not need to buy wound/dressing supplies.
- Sharps removed from resident 20's room.
- All other current resident rooms were checked for sharps and any of concern were removed.
- Discussed with Resident 20 that his bags would be checked upon return from shopping.
- Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back.
- Staff will conduct random room checks and will chart in Resident 20's chart as a treatment.
- This has been added to Resident 20's treatment plan and CNA flowsheet.
- Added a treatment order for nursing documentation for behavior/mood of resident 20.
- Resident 20's behavior documentation will be reviewed at interdisciplinary team (IDT) meetings and as needed with adjustments to care/treatment plan as warranted.
- Admission packet updated regarding review of sharps for safety.
- Resident 20's primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email.
- Resident 20 has been re-educated on proper hand hygiene for infection prevention and sharps.
- Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift.
- They receive this education annually at minimum.
- A skills fair reviewing infection prevention is scheduled and annually for staff.
- Sharps restriction added to admissions packet.
- Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms.
- Staff were educated through onshift message about the removal of sharps for any resident.
- Additional education provided to nursing staff related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room.
- PRN treatment order added to check bags upon returning from shopping outings.
- Staff will also be educated on the random room checks that will be conducted on Resident 20's room for sharps found, those items will be removed and secured in the medication room.
- Treatment order added to document these random room checks for Resident 20, also added to CNA flowsheet to check room twice a day.
Resident Elopement and Fall Risk Management Deficiencies
Penalty
Summary
The report details a deficiency involving the elopement of a resident with severe cognitive impairment from a long-term care facility. The resident, who had a history of elopement and was assessed as a high risk for elopement, managed to leave the facility without staff knowledge. The resident was wearing a wander guard, a device intended to prevent such incidents, but there was no documentation of its functionality being checked as required. The elopement was not immediately detected, and the resident was found outside the facility and returned after a significant delay. Another deficiency involved a resident with cognitive impairment and a history of falls who was found on the floor, naked and covered in feces, after a call light went unanswered for an extended period. The resident had a history of falls and required assistance for all activities of daily living. Despite this, the call light system, which should have alerted staff to the resident's needs, was not responded to in a timely manner. The resident's care plan did not adequately address her high fall risk, and staff failed to anticipate her needs, leading to multiple falls. Interviews with staff revealed a lack of awareness and adherence to policies regarding resident safety and monitoring. Staff were not consistently checking the functionality of safety devices like wander guards, and there was a failure to respond to call lights promptly. The facility's policies on monitoring high-risk residents and ensuring their safety were not effectively implemented, contributing to the deficiencies observed.
Removal Plan
- A message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not able to complete education, they will be required to complete the make-up prior to their next shift.
- RN S was educated on the process for calling DON/Administrator immediately when resident safety is at risk-including elopements. The nurse was also educated on the next step of the policy to initiate a head count of all residents when a door alarm is sounded with no explanation.
- Certified nursing assistant (CNA) T was noted to have missed a toileting round of resident 3. This would have decreased the time of the residents' elopement. The CNA T received a final corrective action for lack of rounding during this shift. This standard will be upheld for any employees that are found to have failed to complete their rounding as ordered/recommended.
- All staff were educated on the importance of rounding on all residents multiple times a shift. Residents with high fall and elopement to chart in the hallways so residents can be in eye site.
- All staff were educated on utilizing our call system as all exit doors are on the call system to notify all staff if an exit door is alarm on the scrolling screen and the radios.
- Assessment of resident was completed, and vital signs taken.
- An elopement drill was completed with day shift. Education was provided to staff involved with elopement.
- A potential elopement alert was initiated due to a phone call from someone in the community stating a resident was outdoors near [NAME] Road. Staff responded to code and facility did head count and everyone was accounted for.
- Hallway and department education is being completed with all staff regarding elopement processes and policy review. Elopement policy/procedure was reviewed, explained what an elopement is, who is considered an elopement risk, steps to take when a potential elopement occurs, who to notify if a resident does elope and how to respond to door alarms and completing head counts if no residents were found when alarm was responded to.
- Resident 3's physician was out to facility and updated again on recent elopement events. Resident 3's physician ordered lab work-up on him as this an increase in his normal behaviors. He also would like an update on how he is doing.
- Elopement Drills will be completed weekly x4. These will be completed on shifts, different days of the week and different locations within the building. Then every other week x 4 weeks.
Failure to Protect Residents from Abuse by Co-Resident
Penalty
Summary
The provider failed to protect two residents from abuse by another resident, leading to a deficiency. Resident 4 was observed inappropriately touching Resident 1, who has severe cognitive impairment due to dementia and psychosis, and Resident 2, who has dementia and amnesia. Both residents were unable to consent or defend themselves. Despite these incidents, the care plans for Residents 1 and 2 were not updated to reflect that they had been victims of inappropriate touching. Interviews with staff revealed that Resident 4 had a pattern of inappropriate behavior, including touching other residents' thighs and breasts. Staff members, including a registered nurse and certified nursing assistants, reported these incidents to the charge nurse and administration. However, the facility's response was inadequate, as the care plans for the affected residents were not updated, and there was a lack of immediate action to prevent further incidents. The facility's policy on abuse and neglect requires prompt investigation and reporting of such incidents, as well as immediate action to prevent further abuse. However, the facility did not adhere to these procedures, as evidenced by the lack of updated care plans and insufficient measures to protect the residents from further abuse by Resident 4. This failure to follow policy and ensure resident safety resulted in a deficiency being cited by the surveyors.
Removal Plan
- 30-minute checks on resident 4 initiated to ensure the safety of all residents.
- Medical director discontinued the use of Sildenafil and will monitor the use of other medications that could lead to sexual temptations.
- Resident 4 was scheduled to be evaluated by a psychiatry provider to rule out dementia or other medical conditions that could cause the more frequent sexual behaviors.
- Resident 4 was seen by a psychiatry provider.
- Care plans have been updated.
- Education was provided to all staff.
- Managers will provide the education to staff that were not in the building and staff will be required to receive the education before they start their next shift.
- All staff will continue to monitor behaviors and safety for all residents.
- Interventions in place will be assessed and will be modified if needed to make sure the issue is being resolved appropriately.
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