Citations in Tennessee
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Tennessee.
Statistics for Tennessee (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Tennessee
A resident admitted with UTI, Enterococcus faecalis bacteremia, and presumptive infective endocarditis had hospital and ID orders for IV ampicillin 2 g q4h to continue through a January stop date, but the Admission Nurse entered an incorrect December stop date into the facility’s system, which was then confirmed by an RN. The care plan and MAR reflected this erroneous end date, and IV ampicillin was administered only until mid-month, then stopped, resulting in 59 missed doses before the error was later discovered. A medication occurrence report cited omitted doses due to admission order and chart check errors, and leadership confirmed that staff and pharmacy failed to catch the discrepancy between the electronic order and the written hospital/ID orders.
A resident admitted with UTI, urinary retention, and Enterococcus faecalis bacteremia had hospital infectious disease orders for Ampicillin 2 g IV Q4H through a January stop date. When admission orders were entered into the eMAR (PCC), the admissions nurse transcribed the stop date incorrectly as December instead of January. Although the pharmacy provider received faxed orders with the correct stop date and was contractually responsible for verifying that faxed orders matched PCC entries, its medical records department did not identify the discrepancy. A pharmacist from the pharmacy provider completed a Drug Regimen Review with no recommendations, and a contracted consultant pharmacist performed an admission Medication Regimen Review and documented no irregularities, despite policies requiring thorough review of orders, documentation, and stop dates. As a result, the IV antibiotic was automatically stopped on the incorrect December date, and the resident missed multiple scheduled doses until the error was discovered and the medication was resumed.
A resident admitted with UTI, Enterococcus faecalis bacteremia, sepsis, anemia, and a presumptively infected atrial thrombus had hospital orders for IV ampicillin q4h and ceftriaxone q12h to run concurrently through a specified January stop date. On admission, the ampicillin order was entered into the EHR with an incorrect December stop date, while the ceftriaxone order was entered correctly. The RN Charge Nurse’s verification and a subsequent 24-hour chart check by an LPN did not detect the incorrect ampicillin stop date, and the care plan also reflected the shortened course. As a result, the resident received ampicillin only until the erroneous December stop date and then missed 59 scheduled doses before the error was later discovered, while ceftriaxone continued as ordered.
A resident admitted with UTI, urinary retention, and Enterococcus faecalis bacteremia had an order for IV Ampicillin every 4 hours with a specified stop date. On admission, an RN entered the wrong stop date into the system, and both the confirming RN and an LPN performing the 24-hour chart check failed to detect that the electronic order did not match the written physician order. Although the pharmacy had the correct stop date and continued sending the medication, it accumulated in the med room until another RN noticed the excess supply and discovered that the antibiotic had been stopped early, resulting in 59 missed doses. Despite facility policies requiring prompt QAPI review and process improvement for medication errors, the error was not brought to an ad hoc QAPI meeting or used to initiate a timely PIP, and was instead deferred to a later scheduled QAPI meeting.
A resident with multiple chronic conditions, though cognitively intact and needing only minimal to moderate ADL assistance, was discharged home without an orderly and coordinated discharge plan. The facility documented that prescriptions were faxed to the resident’s pharmacy of record, but the fax number was left blank and pharmacy records showed discharge medications were not transmitted until a week later. The resident was referred to a home health agency for PT, OT, and nursing, but the agency was out of network and notified the facility it could not admit the resident; no alternative in-network referral was made and calls were not returned. The SSD did not schedule a follow-up appointment with the primary care provider, relying on the resident to arrange it, and key discharge-planning staff, including those responsible for care coordination, were off duty with no designated backups, leading to missed communications and an ineffective discharge plan.
Administration failed to maintain effective financial controls over payroll and the facility checking account after bringing payroll back in-house. The administrator, a social worker/bookkeeper, and an HR/bookkeeper all had authority to process payroll, alter pay rates, track PTO on an internal spreadsheet, and sign checks without board approval. Review of payroll records, timekeeping data, and CPA analyses showed that these three staff members received large, unauthorized cash-outs of vacation and holiday time and reported extensive overtime, far exceeding facility policy and not supported by actual work hours. Time entries for the two bookkeepers were largely manual rather than actual punches, and audit logs showed self-directed pay rate changes. Interviews with the governing board, current administration, and other staff confirmed that Medicare, Medicaid, private pay, and insurance revenues were deposited into the same account from which these inflated payroll disbursements were made, and that there were no effective checks and balances or independent verification of accrued PTO or overtime, affecting funds available for all residents’ care.
The governing body failed to provide effective oversight of the administrator, payroll system, and the facility’s primary bank account, into which Medicare, Medicaid, insurance, and private resident payments were deposited. Facility policy assigned the board responsibility for establishing management policies and ensuring the administrator reported on audits, budgets, staffing, and supplies, but the facility could not produce any governing body policy predating a recent version, and board members described limited visibility into operations. Payroll had been brought back in-house using a new bookkeeping system, and over a 19‑month period the administrator and two bookkeeping staff cashed out more than $140,000 above allowable benefits, while the board received only summarized financial data and did not review detailed payroll records or prior accruals as recommended by a CPA. Personnel manuals from later years were never presented for approval, policy changes were made without board authorization, and key office positions remained vacant, all while the board relied on verbal assurances from the administrator and annual audits as their primary checks and balances. This lack of oversight and accountability for financial operations had the potential to affect all residents receiving care.
A resident on hospice with neurocognitive disorder, dementia, anxiety, and adult failure to thrive experienced a rapid decline with labored tachypnea, tachycardia, clammy skin, and non-verbal signs of pain. A hospice nurse assessed the resident, determined the resident was actively dying, obtained urgent physician orders for Morphine, Ativan, and Hyoscyamine, and verbally instructed an LPN to obtain and administer these comfort medications from emergency stock. Although the faxed orders were successfully transmitted and emergency stock was available, the medications were never transcribed to the MAR or administered, and there was no documented ongoing monitoring after the hospice visit. The resident’s daughter and a family friend reported no assessments or medication administration during critical hours, and the DON and hospice nurse confirmed that the failure to provide the ordered comfort medications resulted in actual harm and that the resident died in agony.
Nursing staff failed to demonstrate appropriate competency in administering Versed and monitoring residents afterward. Two residents with dementia and severe cognitive impairment received IM Versed for agitation or anxiety after other interventions or PRN Ativan were ineffective. Although reference materials and internal job descriptions required monitoring of vital signs and respiratory status with this benzodiazepine, and a memo from the DON instructed that respiratory status must be monitored, no blood pressure, heart rate, or respiratory rate measurements were documented before or after the injections for either resident. The DON provided only a brief memo without specific monitoring time frames or additional training, and interviews showed inconsistent expectations among leadership and staff regarding required monitoring, resulting in Versed being given without documented vital sign assessment or structured observation.
The facility failed to maintain required controlled substance records for Midazolam (Versed) obtained from the emergency med bank, in violation of its own policies on controlled substances and emergency medications. Several residents with dementia, psychiatric conditions, and other comorbidities received one-time IM Midazolam doses for agitation or anxiety after full vials were pulled from the med bank, but there was no documentation of receipt, wasting, or destruction of the unused portions. In multiple instances, narcotic sheets were not completed or retained, and the DON reported that such sheets were shredded. In one case, a nurse saved Midazolam in a med cart and administered it to a resident days later without a PRN order and without a corresponding med bank pull, further preventing accurate reconciliation of the controlled drug.
Failure to Follow IV Antibiotic Orders Due to Incorrect Stop Date Entry
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for IV antibiotic therapy for one resident admitted with a UTI, urinary retention, Enterococcus faecalis bacteremia, and presumptive infective endocarditis. Hospital discharge documentation and an infectious disease (ID) physician note specified that the resident was to receive ampicillin 2 g IV every 4 hours through a specified January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly directed continuation of IV ampicillin at that dose and frequency until mid-January. On admission, the Admission Nurse entered the ampicillin order into the facility’s computer system with an incorrect stop date in December instead of the January stop date ordered by the ID physician. The electronic order was entered to run from the admission date with an end date in mid-December, and this incorrect order was confirmed by the RN Charge Nurse later that same day. The comprehensive care plan for antibiotic therapy also reflected the incorrect December stop date. As a result, the Medication Administration Record (MAR) shows that the resident received ampicillin IV every four hours only from the evening of admission through mid-December, at which point the medication was stopped per the erroneous end date. Because of the incorrect stop date and failure to reconcile the electronic order with the hospital discharge and ID orders, the resident did not receive ampicillin from mid-December until the medication was later resumed in late December, resulting in 59 missed doses of IV ampicillin. A Medication Occurrence Report documented this as an omitted dosage error caused by an admission order error and chart check error, noting that the infectious disease orders in the chart had the correct January stop date while the electronic order had the wrong December stop date. The DON confirmed that the Admission Nurse, the RN Charge Nurse, and the pharmacy consultant did not identify the discrepancy at the time of admission, and that the resident’s ampicillin was discontinued earlier than ordered, leading to the lapse in therapy.
Failure of Pharmacy Services and Consultant Pharmacist to Detect Incorrect IV Antibiotic Stop Date
Penalty
Summary
The deficiency involves a failure of the facility’s pharmaceutical services, including both the contracted pharmacy provider and the consultant pharmacist, to identify a transcription error in an IV antibiotic order, resulting in an incorrect stop date and an extended omission of ordered doses. A resident was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had hospital infectious disease orders for Ampicillin 2 g IV every 4 hours to continue through a specified date in January. The hospital discharge summary and infectious disease note documented Ampicillin 2 g IV every 4 hours with a stop date of January 13. The facility faxed the admission orders to the pharmacy provider, and the order was entered into the facility’s electronic system (PCC) on the day of admission as Ampicillin Sodium Solution 2 g IV every 4 hours, but with an incorrect stop date of December 13 instead of January 13. The order was confirmed in the system later that same day. According to facility policy, the consultant pharmacist is responsible for providing consultation on all aspects of pharmacy services, including helping the facility develop processes for receiving and transcribing medication orders, and for performing a Medication Regimen Review (MRR) for every resident upon admission and at least monthly. The MRR is to include a thorough review of the medical record to prevent, identify, report, and resolve medication-related problems and errors, including omissions of ordered medications and documentation-related errors. The pharmaceutical services agreement with the pharmacy provider also requires that a licensed pharmacist review each resident’s drug regimen, including the medical chart, and report any irregularities to the attending physician, medical director, and DON. The agreement further states that the pharmacy will use an electronic system (PCC) to manage orders and MARs and that the pharmacy’s medical records department is responsible for ensuring that faxed orders match what is entered into PCC. Despite these requirements, multiple review processes failed to detect the incorrect stop date. The pharmacy provider received the faxed admission orders on the day of admission, which correctly showed Ampicillin 2 g IV every 4 hours with a stop date of January 13, but the facility-entered order in PCC reflected a stop date of December 13. A pharmacist from the pharmacy provider performed a Drug Regimen Review on the day of admission and documented that the medications were reviewed with no recommendations. The consultant pharmacist completed an admission Pharmacy Drug Regimen Review three days later and also documented no recommendations or irregularities. The consultant pharmacist later stated that she reviews new admission medications to ensure physician orders match what is entered in PCC and that stop dates are part of this review, and acknowledged she should have identified an incorrect stop date. The pharmacy provider’s Director of Operations confirmed that the medical records department’s verification, completed three days after admission, should have identified the discrepancy between the faxed order’s January stop date and the December stop date entered in PCC but did not. As a result, the MAR shows the resident received Ampicillin IV every four hours from the evening of admission through December 13, when the medication stopped per the incorrect stop date, and the resident then missed 59 doses between December 13 and December 24, when the error was finally identified and the medication was resumed. Interviews further clarified the sequence of events and the roles of involved staff. The DON stated that the admissions nurse entered the Ampicillin order with the incorrect December stop date, causing the medication to stop in error on that date. The DON confirmed that the error was not identified until December 24, at which time an order was obtained to resume the medication, and that the resident missed doses every four hours during the gap period. The Medication Occurrence Report documented the error as an omitted dosage due to an admission order error and chart check error, specifying that the wrong stop date was entered on admission and that infectious disease orders present in the record had the correct January stop date. The pharmacy provider’s Director of Operations confirmed that the faxed order to the pharmacy showed the correct January stop date, that the facility had entered a December stop date into PCC, and that the pharmacy’s medical records verification process should have detected and reported this discrepancy but did not. These combined failures by the facility’s pharmacy services and consultant pharmacist to identify and correct the transcription discrepancy led to the prolonged interruption of the resident’s ordered IV antibiotic therapy.
Omission of 59 IV Ampicillin Doses Due to Incorrect Stop Date Entry and Missed Chart Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when 59 ordered doses of IV ampicillin were omitted. The resident was admitted from the hospital with diagnoses including UTI, Enterococcus faecalis bacteremia, sepsis secondary to UTI, anemia, and a presumptively infected left atrial thrombus. Hospital infectious disease documentation and the discharge summary specified that the resident was to receive ampicillin 2 g IV every 4 hours and ceftriaxone (Rocephin) 2 g IV every 12 hours through a specific January stop date, representing six weeks of therapy after the first negative blood cultures. These written hospital orders, present in the resident’s physical chart, clearly indicated that both IV antibiotics were to continue concurrently through mid-January. On admission, the Admission Nurse entered the IV antibiotic orders into the facility’s electronic system (PCC). While the ceftriaxone order was entered with the correct stop date, the ampicillin order was entered with an incorrect stop date in December instead of the January date ordered by the infectious disease physician. The RN Charge Nurse confirmed the admission orders in the electronic system against the physical hospital orders but did not identify the discrepancy in the ampicillin stop date. A 24-hour chart check was then completed by an LPN, who also failed to detect that the ampicillin stop date in the computer did not match the physician’s written orders. The comprehensive care plan that was initiated likewise reflected the incorrect, shortened ampicillin date range. As a result of the incorrect stop date and the missed verification opportunities, the resident received IV ampicillin every four hours only from the evening of admission through the early evening of the erroneous December stop date. After that point, the ampicillin was automatically discontinued in the system, and the resident did not receive any further doses until the medication was later restarted. Review of the MAR showed that the resident missed 59 doses of IV ampicillin between the erroneous discontinuation date and the date the order was resumed, while ceftriaxone continued to be administered as ordered. The medication occurrence report identified the error as an omitted dosage caused by an admission order error and chart check error, and the DON confirmed that the facility’s medication verification processes were not followed, resulting in the resident not receiving ampicillin as ordered during that period.
Failure to Identify Significant IV Antibiotic Omission and Initiate Timely QAPI PIP
Penalty
Summary
The deficiency involves the facility’s failure to timely identify and address a significant medication error involving omitted doses of IV antibiotics for Resident #1 and to initiate a Process Improvement Project (PIP) through its QAPI program. Facility policies on adverse consequences and medication errors, administering medications, medication regimen review (MRR), and QAPI require that medication errors, including omissions, be promptly identified, reported, analyzed by the QAPI committee, and used to drive process improvements. Despite these policies, the facility did not recognize and elevate a serious omission of ordered IV Ampicillin as a quality deficiency in a timely manner. Resident #1 was admitted with diagnoses including UTI, urinary retention, and Enterococcus faecalis bacteremia, and had an order for Ampicillin IV 2 g every 4 hours with a stop date of 1/13/2026 per infectious disease orders. On admission, the Admissions Nurse entered the stop date incorrectly as 12/13/2025 instead of 1/13/2026. The RN Charge Nurse, responsible for confirming the order, failed to identify that the stop date entered into the computer system did not match the written physician order. LPN A, who performed the 24-hour chart check, also failed to detect the incorrect stop date, even though the procedure required verifying that the written physician’s order matched what was entered into the electronic system. The pharmacy provider entered the correct stop date of 1/13/2026 in its system and continued sending Ampicillin to the facility, resulting in an accumulation of the medication in the medication room. The error was not identified until RN A noticed an abundance of Ampicillin on 12/24/2025 and performed a chart check, revealing that the medication had been stopped 11 days earlier than ordered. This led to 59 missed doses of IV Ampicillin for Resident #1. Interviews with the ADON, Interim Administrator, and DON confirmed that the facility’s medication verification processes were not followed, that the error was considered significant, and that no ad hoc QAPI meeting or PIP had been initiated prior to the next scheduled QAPI meeting, despite the facility’s policies requiring QAPI involvement in reviewing medication errors and implementing process improvements.
Failure to Ensure Safe and Coordinated Discharge Planning and Medication Provision
Penalty
Summary
The deficiency involves the facility’s failure to execute an orderly and effective discharge for one cognitively intact resident who was discharged home. Facility policy on transfer or discharge required that information such as disposition of medications and confirmation that receiving providers’ services were available to meet the resident’s needs be communicated at discharge. The resident had multiple diagnoses, including aphasia following cerebral infarction, type 2 diabetes with neuropathy, unspecified dementia, depression, duodenal ulcer, and fibromyalgia, but was assessed as cognitively intact with no behavioral issues and needing only minimal to moderate assistance with activities of daily living. At discharge, the facility’s discharge summary identified the resident’s pharmacy of record and stated that prescriptions were conveyed to the pharmacy by fax, but the pharmacy fax number line was left blank. Review of pharmacy records showed that discharge medication orders were not actually transmitted to the pharmacy until seven days after discharge, and there was no evidence that prescriptions were sent at the time of discharge as documented. The DON later confirmed the facility could not provide any information showing that prescriptions were faxed on the discharge date and that the electronic transfer of prescriptions occurred a week later, after a family complaint. The facility also failed to ensure appropriate post-discharge services and follow-up medical care were arranged. The resident was referred to a local home health agency for PT, OT, and nursing services, but the agency was out of network for the resident’s insurance and therefore did not admit the resident. The home health service director reported notifying the facility on the day of referral that the resident was not eligible, but the facility did not return the call or make an alternative in-network referral. The SSD, who coordinated the discharge, did not schedule a follow-up appointment with the resident’s primary care physician, stating the resident said she would do it herself, and was unaware that the home health provider was out of network. The DON and Administrator confirmed that multiple staff responsible for discharge planning and care coordination were off duty over the holidays, no backup personnel were designated, and messages from the home health provider were not relayed, resulting in a failure to provide a safe and effective discharge plan for the resident’s wound care, therapy, and medication needs.
Failure of Administrative Oversight Allowed Payroll Mismanagement and Excessive PTO Cash-Outs
Penalty
Summary
Administration failed to ensure appropriate checks and balances over the facility’s payroll system and checking account after payroll was brought back in-house. The governing body had appointed an appropriately licensed administrator who, per job description, was responsible for overall facility operations, instituting controls to ensure efficient and economical operation, limiting overtime, certifying payrolls, and ensuring timely deposits. However, the personnel plan and benefit structure implemented by the administrator was not approved by the governing body, and the facility relied on a manually maintained spreadsheet for tracking staff vacation, sick, holiday, and compensatory time. Staff could not independently verify their accrued time and had to rely on the social worker/bookkeeper to report balances. When payroll was moved from an outsourced vendor back into the facility, three office staff members—the administrator, the social worker/bookkeeper, and the HR/bookkeeper—had access to payroll records, the bookkeeping system, and the facility’s checking account, and all three could sign checks without board approval. Review of W-2s and payroll stubs showed that, after payroll was brought in-house, these three employees received large increases in total compensation, including substantial cash-outs of vacation and holiday time and significant overtime payments. Timeclock records showed that for the two bookkeepers, most time entries were manually entered rather than recorded by actual punches, and both reported very high overtime hours despite interview statements from another RN/administrative assistant that these two did not work overtime. The benefit plan limited vacation cash-out to no more than three days per pay period, but payroll records and CPA analysis showed that the three employees cashed out holiday and vacation time far in excess of policy limits. External CPA review of payroll and bank activity over a 19‑month period identified that the social worker/bookkeeper, HR/bookkeeper, and administrator collectively received $142,627.44 more in holiday and vacation cash-outs than allowed by facility policy, even under generous assumptions about maximum accruals. The bookkeeping system audit trail showed that the social worker/bookkeeper changed her own hourly rate and the administrator’s hourly rate upward during the audit period, then changed them back. Interviews with the board chairman, the current administrator, the RN administrative assistant, and the business office manager confirmed that the three office staff controlled which bills were paid, wrote and signed checks, and processed payroll without effective oversight or dual controls. The chairman reported that the three employees “took the money from the bank account,” which was funded by Medicare, Medicaid, private pay, and insurance revenues, and acknowledged that the facility was probably not administered as it should have been. The surveyor concluded that administration failed to provide oversight of payroll and staff with access to the checking account, resulting in financial mismanagement that had the potential to affect all residents whose care depended on those funds. The facility’s own policies required the administrator to implement procedures and controls to meet budgetary projections, limit overtime, and ensure efficient operation, and the board of directors was to oversee administration with proposals directed to them for consideration. Nonetheless, the administrator relied on the payroll clerk’s spreadsheet for tracking compensated absences, did not verify her own pay or the pay of the two bookkeepers, and did not monitor overtime or cash-outs against policy limits. The auditors found no reliable compensated absences report to support the large cash-outs, and the administrator acknowledged that she trusted staff under her, did not review her check stubs, and did not check the bookkeepers’ time even though she knew they were not working overtime. The lack of segregation of duties, absence of independent verification of accrued time, and failure to require board approval or dual signatures for payroll-related disbursements allowed the three employees to manipulate payroll and cash-outs using funds derived from Medicare, Medicaid, private pay, and insurance payments for resident care.
Governing body failed to oversee administrator, payroll, and facility bank account
Penalty
Summary
The deficiency involves the governing body’s failure to provide effective oversight of facility management and financial operations, including payroll and the primary facility bank account into which Medicare, Medicaid, insurance, and private resident payments were deposited. Facility policy dated 10/9/2025 stated that the governing body was legally responsible for establishing and implementing policies for management and operation of the facility, appointing an administrator who was responsible for management, and ensuring a process for the administrator to report on audits, budgets, staffing, and supplies. The facility was unable to produce any governing body policy that was in effect prior to 10/9/2025. Board members and the chairman described their role as mainly policy-making and oversight, with the administrator as the only employee of the board, but they relied largely on verbal reports and limited written financial information from the administrator. Governing body minutes showed that payroll had been brought back in-house after previously being outsourced, and that a new bookkeeping system was implemented. Over multiple meetings, the board received high-level financial reports from a CPA, including reports of profits and losses, but there were gaps in financial reporting, such as a meeting where financials were not reported due to the absence of the administrator and CPA. The minutes also documented that personnel manuals from 2022 and 2023 were never presented to the board for approval, even though earlier manuals had been approved, and that key office positions such as Social Services, Human Resources, and Business Office Manager were vacant. Board members later learned that policy manuals had been revised without board approval and that multiple versions of the policy manual were in circulation. A spreadsheet from CPA Firm #1 covering a 19‑month period showed that the administrator and two bookkeeping staff cashed out a total of $142,627.44 over the maximum benefit allowed by facility policy. An analysis from the CPA identified three employees who far exceeded the window for payroll payouts after payroll was brought back in-house and recommended that the board review prior auditors’ accruals for vacation, holiday, and sick leave and interview prior administrators about vacation restrictions during COVID. The chairman later acknowledged that he did not think the board had reviewed those accruals or discussed the CPA’s letter. Interviews with board members revealed that their primary checks and balances were annual audits and review of summarized financial statements, that they did not have detailed visibility into payroll or individual salaries, and that they were unaware of staff turning in hours worked at home. The board members stated they were blindsided when an external auditor identified significant unexplained salary increases for the administrator and two bookkeeping staff, and they acknowledged that the governing body had “dropped the ball” on ensuring the administrator was held accountable and that policy changes and financial operations were properly reviewed. The failure of the governing body to oversee the administrator, payroll system, and bank account was determined to have the potential to affect all 45 residents in the facility. The chairman reported that during the tenure of a prior administrator, payroll had been outsourced to an out-of-state firm without the board’s knowledge, which contributed to that administrator’s departure. Afterward, the administrator and a bookkeeper recommended bringing payroll back in-house, and the board accepted their assurances that there were no problems. The chairman stated that he questioned the administrator and visited the facility but relied on the information provided and did not receive the level of financial detail he felt was needed. Board members described that they received total salary figures as a blanket line item and general expense breakdowns, but not detailed salary registers or clear tracking of compensated absences. One board member stated that the governing body’s oversight and visibility into operations were limited and that they had not been given copies of the policy manual, despite the policy requiring a process for holding the administrator accountable for reporting on management and operations. Another board member linked the unapproved 2023 personnel handbook changes, including wording that allowed staff to cash in time, to the financial issues, noting that the way the policy was written contributed to increased payouts. Throughout interviews, board members and the chairman acknowledged that they relied heavily on trust in the administrator and did not implement or follow through on robust checks and balances to detect or prevent mismanagement of payroll and the facility’s bank account.
Failure to Administer Hospice Comfort Medications to Actively Dying Resident
Penalty
Summary
The deficiency involves the facility’s failure to timely transcribe and administer hospice physician comfort-medication orders for a resident who was actively dying and on hospice services. Facility policies on pain management and medication administration required prompt recognition and assessment of pain, implementation and carrying out of physician orders, and timely administration of medications, with documentation of any reason for not administering medications. The resident had diagnoses including Neurocognitive Disorder with Lewy Bodies, unspecified dementia, anxiety disorder, adult failure to thrive, and was on hospice services with a Do Not Resuscitate status. A quarterly MDS showed the resident was cognitively intact but required moderate to maximal assistance with activities of daily living. On the morning in question, the hospice nurse arrived at approximately 10:30 AM after being contacted by the resident’s daughter about a change in condition. The hospice nurse assessed the resident and documented that the resident had an expected very short life expectancy of days to one week, was near death, used non-verbal indicators of pain, had labored tachypnea at 32 breaths per minute, tachycardic and irregular heart rate at 132 beats per minute, warm and clammy skin, and no oral intake for two days. The hospice nurse determined the resident was actively dying and obtained physician orders for Morphine Sulfate, Ativan (Lorazepam), and Hyoscyamine, with scheduled and PRN dosing for comfort and secretion control. These written orders were faxed to the facility and pharmacy at 11:26 AM, marked urgent. The hospice nurse reported giving verbal orders and specific instructions to the LPN on duty to obtain the medications from the facility’s emergency stock and administer them immediately. Despite these orders and instructions, the medical record and Medication Administration Record showed no evidence that the comfort medications were transcribed into the resident’s MAR or administered at any time before the resident’s death that afternoon. Nurse’s notes by the LPN at 2:02 PM documented elevated heart rate, rapid respirations, lack of eating or drinking, and that the hospice nurse had evaluated the resident and stated the resident was actively dying, but there was no documentation of comfort-medication administration or ongoing monitoring after the hospice visit. The resident’s daughter reported observing her mother with altered mental status, faint moaning, rapid shallow breathing, pale and moist skin, and appearing in distress earlier that morning, and stated that during her absence from approximately midday until about 2:00 PM, a family friend at the bedside did not see staff assess or medicate the resident. Upon her return, the daughter questioned the LPN about the lack of Morphine or other medications and was told the medications were awaiting pharmacy delivery; the hospice nurse later informed the daughter that the medications could have been taken from the facility’s emergency stock. The former DON confirmed that Morphine, Lorazepam, and Hyoscyamine were maintained in emergency stock and could have been used immediately. The DON verified there was no evidence the ordered medications were administered, and the hospice nurse stated that the failure to administer comfort medications caused harm and, in her professional judgment, caused the resident to die in agony.
Failure to Monitor Vital Signs and Respiratory Status After Versed Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff had and used the competencies and skills necessary to safely administer midazolam (Versed) and monitor residents afterward. Reference materials reviewed by surveyors, including a National Library of Medicine article and the drug’s Black Box Warning, stated that midazolam is a short-acting benzodiazepine used for sedation and anxiolysis, with known risks of profound sedation, respiratory depression, hypotension, respiratory arrest, hypoxic encephalopathy, coma, and death. These sources emphasized the need for monitoring vital signs such as blood pressure, heart rate, and respiratory rate, especially in older patients, and called for continuous monitoring of respiratory and cardiac function. The facility’s LPN job description and nursing services policy required nurses to observe and evaluate residents’ responses to medications, maintain competency, use critical thinking, and perform pertinent medical assessments such as vital signs as ordered or as needed. The facility issued a memo from the DON stating that Ativan IM was on national back order and that Versed would be used in its place for anxiety/agitation. The memo indicated that Versed is in the benzodiazepine class, FDA-approved for anxiety/agitation in low doses, and that respiratory status would need to be monitored when it was given, instructing nurses to familiarize themselves with the medication. However, the DON did not specify a time frame or parameters for monitoring and acknowledged that no further training was provided beyond this memo. In interviews, the DON stated she would expect staff to monitor for changes in respiratory status and distress but indicated that obtaining vital signs before and after Versed administration would be on a case-by-case basis. The Medical Director stated that staff should monitor using nursing judgment and referenced a three-hour window of monitoring, while an NP and one LPN later acknowledged that residents should have vital signs taken before and after Versed administration and be watched closely for changes in breathing. For Resident #11, who had dementia, Alzheimer’s disease, major depressive disorder, psychosis, and severe cognitive impairment (BIMS score of 5), a nurse practitioner ordered midazolam 2.5 mg IM one time for increased aggression and agitation after the resident refused oral medications. The MAR showed Versed 2.5 mg IM was administered by an LPN, but the weights and vitals summary for that month showed no blood pressure, heart rate, or respirations obtained before or after the injection. For Resident #12, who had dementia, mood disorder, anxiety disorder, and severe cognitive impairment (BIMS score of 6), PRN Ativan was reported as not effective for increased anxiety and combative behavior, and a new order for midazolam 2.5 mg IM one time for anxiety was obtained. The MAR documented administration of Versed 2.5 mg IM by another LPN, and progress notes confirmed the new order and administration, but the weights and vitals summary showed no vital signs taken before or after the dose. In interview, that LPN confirmed no vital signs were obtained when Versed was administered. These actions and inactions demonstrated that nursing staff did not perform the necessary monitoring and assessments associated with Versed administration for two residents.
Failure to Maintain Required Controlled Substance Records for Midazolam
Penalty
Summary
The deficiency involves the facility’s failure to maintain required records for receipt, administration, wasting, and destruction of the controlled substance Midazolam (Versed) obtained from the emergency medication supply (med bank), contrary to its own policies on emergency medications, controlled substances, and pharmacy services. Facility policies required an individual controlled substance record for each resident receiving a controlled drug, including documentation of quantity received, number on hand, time of administration, and nurse signatures, as well as two nurses to witness dispensing and wasting from the emergency supply. Despite these requirements, the facility was unable to produce narcotic sheets or other documentation showing proper receipt and disposition of Midazolam for four residents. For one resident with Alzheimer’s disease, COPD, CHF, psychosis, and wandering, who had intact cognition and no noted behaviors on assessment, an order was written for a one-time intramuscular dose of Midazolam for agitation. A 1 ml vial of Midazolam 5 mg/ml was pulled from the emergency med bank, and 2.5 mg (0.5 ml) was administered, but the facility could not provide documentation of the medication’s receipt or the disposal of the unused portion. For another resident with cerebral infarction, vascular dementia, and depression, who had moderately impaired cognition and physical and verbal behaviors interfering with care, two separate one-time IM Midazolam orders were written on consecutive days. Each time, a 1 ml vial was pulled from the med bank and 2 mg (0.4 ml) was administered, yet the facility again lacked documentation of receipt and disposal of the remaining Midazolam. For a third resident with dementia, Alzheimer’s disease, major depressive disorder, and psychosis, who had severe cognitive impairment and no noted behaviors on assessment, a one-time IM Midazolam order for agitation was written, a 1 ml vial was pulled, and 2.5 mg (0.5 ml) was administered, but no documentation of receipt or wasting of the unused medication was available. For a fourth resident with dementia, mood disorder, and anxiety disorder, who had severe cognitive impairment and no noted behaviors on assessment, a one-time IM Midazolam order was written and a 1 ml vial was pulled; however, the MAR showed a higher dose administered than ordered, and the facility could not provide documentation of receipt and reconciliation. A later one-time Midazolam order for this same resident was administered without any corresponding med bank pull, and the DON stated that the nurse had saved the prior Midazolam dose in the med cart for 10 days and then administered it, despite there being no PRN order. Multiple LPNs either did not recall or confirmed that narcotic sheets were not completed, and the DON reported that narcotic sheets were shredded and not retained, leaving no accurate accounting of controlled drug receipt, use, wasting, or destruction for these residents.
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