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)
Some of the Latest Corrective Actions taken by Facilities in Tennessee
- Implemented ongoing Fall, Care plan, Kardex, and Policy audits with concurrent staff education on two-person assist procedures (J - F0689 - TN)
- Established daily fall monitoring to identify trends and adjust interventions promptly (J - F0689 - TN)
- Maintained continuous updates of care plans and Kardexes to reflect current two-person assist requirements (J - F0689 - TN)
- Maintained ongoing competencies and return-demonstration training on resident positioning and repositioning (J - F0689 - TN)
- Measured education effectiveness through daily fall tracking and skills observation (J - F0689 - TN)
- Continued a Quality Assurance Plan for ongoing oversight of the Fall Prevention Program, Resident Safety, and Repositioning practices (J - F0689 - TN)
- Conducted comprehensive facility-wide in-service training on Fall Prevention, Safety and Supervision, and Repositioning for all nursing and respiratory staff, including agency and LOA personnel (J - F0689 - TN)
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who required assistance with mobility and activities of daily living. In the first incident, a non-verbal, cognitively impaired resident who was totally dependent on staff for mobility and required two-person assistance with bed mobility was being repositioned by two CNAs. One CNA left the room to retrieve additional supplies, leaving the other CNA alone with the resident, who was still positioned on her side. The resident's weight shifted, causing her to fall from the bed and sustain a significant head injury, resulting in a traumatic brain injury and hospitalization. Both CNAs and facility leadership confirmed that the resident was known to require two-person assistance and that the policy was not followed when one CNA left the room during care. In the second incident, another resident with moderate cognitive impairment, Parkinson's disease, muscle weakness, and a history of repeated falls was found on the floor after an unwitnessed fall. The resident complained of severe pain and inability to move her right leg, and requested an x-ray. Staff assisted the resident to bed and then used a mechanical lift to transfer her to a wheelchair, despite her complaints of pain and immobility. There was a delay of over six hours before emergency transport was called to take the resident to the hospital, where she was diagnosed with a displaced subcapital right femoral neck fracture. Interviews revealed that staff did not immediately call 911 and moved the resident despite her symptoms, contrary to expected protocol. The facility's policies required two-person assistance for certain residents and outlined procedures for responding to falls and pain management. However, in both cases, staff failed to follow these protocols, resulting in significant harm to the residents. The incidents were confirmed through medical record review, staff and family interviews, and facility investigations, and led to the identification of Immediate Jeopardy due to the serious injuries sustained by the residents.
Removal Plan
- Educated CNA A and CNA B on 2-person assist with bed mobility and positioning and repositioning the resident while providing care.
- Reviewed all falls, policies, Kardex's and care plans to align with each resident's current bed mobility needs.
- Began in-servicing on Fall Management Program, Safety and Supervision of the Resident, and Positioning and Repositioning of the resident for all licensed Nurses, CNAs, and Respiratory Therapist.
- Implemented Fall audits, Care plan audits, Kardex audits, Policy audits, and on-going education with Licensed Nurses, CNAs, and Respiratory Therapist on 2-person assist with bed mobility to call for help and not leave the room if they need any supplies.
- Conducted skills competency with positioning and repositioning residents with return demonstration to prevent recurrence.
- Monitoring all falls daily.
- Ensuring all care plans and Kardex's are up to date.
- Ongoing competencies and education to ensure training is effective.
- Measuring effectiveness of the in-services by monitoring the falls on a daily basis and observing return demonstrations through competency.
- Conducted a facility wide fall audit with no major injuries.
- Conducted a facility wide care plan audit to ensure any resident that is a 2-person assist reflects accurately and was found to be up to date.
- Conducted a facility wide Kardex audit to ensure all residents had an up-to-date Kardex and aligning with current care plan with 2-person assist with bed mobility.
- Reviewed policies on Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by the Administrator and Director of Nursing with no revisions needed.
- In-serviced all licensed Nurses, CNAs, Respiratory Therapist, any nursing agency personnel and any Nurses, CNAs, Respiratory Therapist on Leave of Absence (LOA) on Fall Prevention, Safety and Supervision of Residents, and Repositioning.
- Continuing ongoing Quality Assurance Plan to monitor facility performance and compliance with the Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by continuing to monitor falls daily and implementing planned interventions and approaches appropriately.
Failure to Provide Appropriate Pain Management Resulting in Actual Harm
Penalty
Summary
The facility failed to provide appropriate pain management consistent with professional standards of practice for two residents who required such services. One resident, who was severely cognitively impaired and dependent on staff for all care, was readmitted after a right below-the-knee amputation. Upon admission, this resident's pain was assessed as moderate to severe, and physician orders included Hydrocodone for moderate pain and Ibuprofen for mild pain. Despite these orders, the facility did not administer Hydrocodone as needed for pain, resulting in the resident experiencing uncontrolled pain, as evidenced by restlessness, trembling, and new behaviors such as attempting to climb out of bed. The resident subsequently sustained an unwitnessed fall with a head injury, leading to hospitalization and diagnosis of subarachnoid hemorrhage and a periorbital fracture. The facility lacked a system to assess and address pain in residents with cognitive impairment, and there was no documentation of pain management interventions in the care plan. Another resident, also with severe cognitive impairment and dependent on staff, sustained an unwitnessed fall. Later, the resident exhibited intense pain through verbal complaints and nonverbal cues such as hollering, grimacing, and guarding the right hip and femur. The practitioner was not immediately notified, and the resident did not receive pain medication. A STAT x-ray was ordered and obtained hours later, revealing a periprosthetic fracture. The resident was transferred to the hospital without having received pain medication prior to transfer. Documentation did not reflect administration of pain medication, and staff interviews confirmed that pain management was not provided during the period of distress. Interviews with staff and review of records revealed multiple failures, including lack of follow-up when pain medications were not available, inadequate pain assessment for cognitively impaired residents, and insufficient documentation of pain management. Staff were aware that pain medications were not delivered or available, but did not take appropriate steps to resolve the issue or utilize available emergency supplies. The facility's policies required documentation and communication regarding pain management, but these were not followed, resulting in actual harm to both residents.
Removal Plan
- Root Cause Analysis was completed.
- Facility-wide audit of all residents with pain medication orders included confirmation the ordered pain medication was available on-site.
- Order request was sent to the pharmacy for a resident needing a re-fill of pain medication; resident received medication from the E-kit until the re-fill arrived.
- Pain Assessment/Management In-service training records were reviewed, including sign-in sheets and cross-referenced with current nursing staff including agency nursing.
- All nurses currently working had received pain assessment and management in-service training.
- Nursing staff were interviewed to describe the training received related to pain assessment, monitoring, and management.
- Training was conducted in person as well as electronically via the online training software.
Latest Citations in Tennessee
The facility did not ensure sanitary food storage and preparation, with food items found unlabeled and undated, baking pans containing carbon build-up, and a grease trap under the stove filled with food debris. The walk-in cooler temperatures were consistently above the required range for an extended period, and food was not discarded promptly despite policy requirements. These deficiencies were confirmed by dietary management and the administrator, affecting meal service for most residents.
Staff failed to follow hand hygiene protocols during medication administration, including not performing hand hygiene between glove changes and before or after administering medications to multiple residents. These lapses were observed among an RN and two LPNs, contrary to facility policy and as confirmed by the DON.
A resident with multiple diagnoses, including atrial flutter and dementia, was incorrectly coded on the MDS assessment as having received antiplatelet medication during the 7-day look-back period, despite the medication being discontinued and not administered during that time. The error was confirmed by the MDS Coordinator and DON through review of the MAR and staff interviews.
A resident's medical record inaccurately documented the presence of both upper and lower dentures, when in fact the resident only had an upper denture and some natural lower teeth. This discrepancy was confirmed through observation, interviews with the resident's daughter, and facility staff, revealing that the lower denture had been discarded prior to admission and not replaced.
The facility did not ensure privacy for a resident group meeting, as non-participating staff and visitors entered the meeting space and interrupted the proceedings. An activity supervisor confirmed that such interruptions are a recurring problem, and the administrator acknowledged that meetings are supposed to be uninterrupted.
Two residents with cognitive impairments who required supervision during meals were observed feeding themselves in the dining room without any staff present to assist or supervise, contrary to facility policy.
Surveyors identified unsanitary conditions in the kitchen, including an ice machine with black spots, expired sugar in use, and wet nesting of steam pans. The Certified Dietary Manager confirmed these issues, which were not in compliance with facility policies. All residents were receiving meal trays from the affected kitchen.
Two nurses failed to follow proper hand hygiene protocols during medication administration for two residents, including not changing gloves or performing hand hygiene between tasks and not using a clean paper towel to turn off the faucet after washing hands, contrary to facility policy.
A resident with a history of stroke, dementia, and high fall risk experienced a fall when staff failed to ensure a weight-based alarm mat was in place on the wheelchair as ordered. Staff confirmed the alarm was not used at the time of the incident, despite care plan and physician orders requiring its use for fall prevention.
A resident who was hospitalized for an extended period returned to find personal belongings, including a statue and a decorated tree, missing from their room. Facility staff reported that items left behind were boxed, labeled, and stored, but those unclaimed after 30 days were discarded per previous administrative instruction. The resident's family was not notified prior to the disposal, and the facility lacked a policy on handling personal items after a resident's absence.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store, handle, prepare, and serve food under sanitary conditions, as evidenced by multiple observations and documentation. Food items were found unlabeled and undated, including an open bag of white powder (thickening powder for drinks) left on top of a flour bin. Eight large rectangular baking pans were observed with carbon build-up, and a grease trap drawer under the stove was found with excessive tearing of aluminum foil, a black plastic lid, and a large amount of food debris. These conditions were confirmed by the Regional Certified Dietary Manager (CDM) and the CDM during interviews. Additionally, the walk-in cooler temperatures were consistently recorded above the acceptable range of 35 to 41 degrees Fahrenheit, with numerous documented instances of temperatures ranging from 42 to 58 degrees over a period of nearly two months. Despite facility policy requiring immediate reporting and action for unacceptable refrigerator temperatures, the elevated temperatures persisted, and the food in the cooler was not discarded until a new refrigerator was purchased. The Administrator confirmed being informed about the elevated temperatures only twice and acknowledged that the dietary staff had not reported the abnormal temperatures as required by policy. The census at the time was 37, with 34 residents receiving meal trays from the kitchen.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during medication administration for three residents. Facility policy required hand hygiene before direct contact with residents, before applying gloves, and after removing gloves. However, observations revealed that staff did not consistently perform hand hygiene at the required times. Specifically, one LPN did not perform hand hygiene between glove changes while administering eye drops to a resident. Another RN failed to perform hand hygiene before and after administering medications and removing gloves. A third LPN did not perform hand hygiene before preparing medications, before and after glove changes, and after administering medications, including eye drops and an inhaler. Interviews with the Director of Nursing confirmed that staff were expected to perform hand hygiene as outlined in facility policy, including before preparing medications and between glove changes. The observed lapses in hand hygiene occurred during direct care and medication administration to residents, as documented by surveyors during their review and interviews.
Inaccurate MDS Assessment for Antiplatelet Medication Administration
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident in relation to unnecessary medications. According to the report, the MDS assessment indicated that the resident received antiplatelet medication during the 7-day look-back period. However, a review of the Medication Administration Record (MAR) showed that the resident's order for Aspirin, an antiplatelet, was discontinued and the last dose was administered prior to the resident's hospitalization. The resident did not receive any antiplatelet medication during the 7-day look-back period covered by the MDS assessment. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the MDS assessment was incorrectly coded, as the resident had not received antiplatelet medication during the specified period. The DON stated that it was her expectation for MDS assessments to be accurate, and acknowledged that the assessment in question was not accurate regarding the administration of antiplatelet medications. The resident involved had a medical history including atrial flutter, anxiety, dementia, hypertension, and required assistance with personal care.
Inaccurate Medical Record Documentation of Dentures
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for one resident. The resident was admitted with multiple diagnoses, including congestive heart failure, anxiety, dementia, and prediabetes. Documentation in the medical record, including the Long Term Care Evaluation, indicated that the resident had both upper and lower dentures. However, observation and interviews revealed that the resident only had an upper denture and some natural teeth on the bottom, with missing lower teeth. The resident's daughter confirmed that the bottom denture had been discarded prior to admission and was not replaced, which was also corroborated by the DON and Administrator. Despite these facts, the medical record inaccurately documented the presence of both upper and lower dentures. The DON confirmed that the assessment stating the resident had both dentures was not accurate. The expectation was that nursing assessments should be complete and accurate, but this was not met in this instance, resulting in an inaccurate medical record for the resident.
Failure to Provide Privacy for Resident Council Meeting
Penalty
Summary
The facility failed to provide a private and uninterrupted space for the Resident Council meeting, as required by its own policy and federal regulations. During the observed meeting, the Transportation Driver remained in the room while the meeting was in progress, and later allowed a family member to enter, who then interacted with a resident attending the meeting. Additionally, another resident entered the dining room to access the snack machine during the meeting. The Activity Supervisor confirmed that such interruptions are a recurring issue, and the Administrator acknowledged that Resident Council meetings are supposed to be uninterrupted. These actions and inactions resulted in the residents' right to organize and participate in private group meetings being compromised.
Failure to Provide Supervision During Dining
Penalty
Summary
The facility failed to provide required supervision and assistance during mealtime for two residents who needed such support. According to facility policy, there should be a process in place to ensure residents receive appropriate assistance and supervision during dining. Medical record reviews showed that one resident was severely cognitively impaired and required supervision with eating, while another was moderately cognitively impaired and also required supervision. During an observation in the dining room, both residents were seen feeding themselves without any staff present to supervise or assist. The administrator later confirmed that staff should have been present to supervise residents during meals.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, as evidenced by several observations during a survey. One of two ice machines was found to have multiple black spots on the interior walls, indicating a lack of proper cleaning and sanitization. Additionally, a container of sugar in the kitchen was observed to be past its use-by date, and the Certified Dietary Manager (CDM) confirmed that the sugar should have had a current use-by date. These findings were in direct violation of the facility's own policies regarding general sanitation, food storage, and cleaning procedures. Further observations revealed improper dishware handling, with multiple instances of wet nesting among steam pans of various sizes. Specifically, several small, medium, and large steam pans were stacked while still wet, contrary to the facility's policy requiring air drying before stacking. The CDM acknowledged that pans should be air dried prior to being put away. At the time of the survey, the facility had a census of 52, with all residents receiving meal trays from the kitchen.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for two residents. In one instance, a registered nurse administered oral medications to a resident with Parkinson's Disease, Diabetes, and Chronic Kidney Disease, and then immediately proceeded to administer eye drops without changing gloves or performing hand hygiene. This action was observed during a medication pass and was not in accordance with the facility's hand hygiene policy, which requires hand hygiene after contact with objects in the resident's vicinity and after removing personal protective equipment. In another instance, a registered nurse performed hand hygiene but turned off the faucet with her wet hand after washing, rather than using a clean paper towel as required by policy. This occurred during medication administration for a resident with a history of infection and inflammatory reaction due to cardiac and vascular devices, acute respiratory failure, and pyelonephritis. The Director of Nursing confirmed during interviews that these actions were not consistent with facility policy.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to follow established interventions to prevent falls for a resident with significant risk factors. The resident had a history of hemiplegia, hemiparesis following a stroke, dementia, Alzheimer's disease, unsteadiness, a femur fracture, and osteoporosis, and was assessed as having memory problems, severely impaired decision-making, daily wandering, and required assistance with activities of daily living. The care plan and physician's orders required the use of a weight-based alarm mat to be in place on the resident's wheelchair to alert staff if the resident attempted to get up, due to impulsive behaviors and high fall risk. On the date of the incident, the resident was found on the floor after having been last seen sitting in a wheelchair in the lobby. Documentation and staff interviews confirmed that the weight-based alarm mat was not in place on the wheelchair at the time of the fall, contrary to the care plan and physician's orders. Staff, including the LPN and CNA, acknowledged that the alarm mat should have been in use and demonstrated that the alarm would have sounded if the resident had leaned forward as described in the incident. The DON confirmed that fall prevention devices should be in place as ordered.
Failure to Safeguard Resident's Personal Belongings After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's right to retain personal possessions following a hospitalization. The resident, who was cognitively intact and dependent on ventilator and personal care, was hospitalized for approximately one month. Upon return, the resident and their family discovered that personal belongings, including a statue and a small decorated tree, were missing from the resident's room. The family reported the missing items to facility staff, but the items could not be located. The Housekeeping Manager confirmed that some items, such as a journal and devotional book, were found and returned, but the statue and tree were not recovered. Facility staff interviews revealed that housekeeping boxed and labeled resident belongings and stored them on the third floor when a resident left the facility. Items stored for 30 days or more were discarded, following instructions from a previous administrator, due to storage space limitations. The Social Services Director and Social Worker did not recall contacting the resident's family to notify them about the impending disposal of the belongings. The facility did not have a policy regarding the disposal of resident personal items, and the Regional Clinical Director was unaware of the 30-day discard practice.
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