Citations in Texas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Texas.
Statistics for Texas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Texas
A resident with muscle weakness, unsteady gait, osteoporosis, cognitive impairment, and a high fall risk required assistance with transfers and had been recommended for sit-to-stand mechanical lift use and gait belt support. The care plan and medical record contained only general language about assistance and transfer aids and did not clearly specify the exact transfer method or device to be used. Despite knowing the resident’s transfer status and prior use of a sit-to-stand lift, a CNA attempted a bed-to-wheelchair transfer using only her hands, without a gait belt or mechanical lift, during which the resident’s knee gave out and she ended up kneeling on the floor, later found to have a left hip fracture. Staff interviews confirmed that transfer aids should have been used and that there was no documentation of the resident refusing the sit-to-stand, while the DON acknowledged not following up on therapy’s recommendation to formalize and implement the sit-to-stand transfer in the resident’s plan of care.
The facility failed to ensure that comprehensive MDS assessments accurately reflected the use of mechanical lifts and sit-to-stand devices for multiple residents with muscle weakness, unsteadiness, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting. Several residents reported being transferred with machines, and surveyors observed CNAs using Hoyer lifts and sit-to-stand devices, yet the corresponding MDS assessments did not code mechanical lift use, and physician orders were absent. Care plans either referenced mechanical lifts without matching orders or mentioned only generic adaptive equipment without specifying transfer aids, despite residents requiring staff assistance for transfers and ADLs.
The facility failed to develop and implement comprehensive, person-centered care plans that specified the use of mechanical lifts for several residents with muscle weakness, unsteadiness, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting. Although some residents reported being transferred with a machine and surveyors observed CNAs using a sit-to-stand device, the MDS assessments did not document mechanical lift use, the care plans only referenced generic adaptive equipment or assistance with transfers, and there were no corresponding physician orders for sit-to-stand or Hoyer lifts. This resulted in residents receiving transfers via mechanical lifts that were not clearly identified or individualized in their care plans as required by facility policy.
Surveyors found that several shared rooms lacked proper privacy curtains for one of the bed spaces, including one room with no curtain or ceiling track, another where the curtain was used to cover an uncovered window leaving the bed end exposed, and a third with a track but no curtain installed. Staff including an LVN, CNAs, an RN, and the Activity Director all acknowledged that privacy and dignity are important for residents’ self-esteem and comfort, and CNAs reported that repair and installation needs were to be entered in a maintenance logbook, but the missing or misused curtains remained unaddressed, leaving affected residents without full visual privacy during care.
Two residents with cognitive impairment and ADL self-care deficits were observed in public areas without adequate protection of their privacy and dignity: a female resident was seated in the lobby and later in the dining room without clothing from the waist down, with her brief and leg exposed up to the hip, and a male resident with an indwelling urinary catheter was in the dining room with his urine collection bag hanging from his wheelchair without a privacy cover. Staff interviews confirmed awareness of the importance of dignity and privacy, and facility policy required residents to be treated with respect and dignity.
Two residents experienced lapses in infection control when staff did not follow PPE and hand hygiene protocols during wound care and peri-care. One resident with a stage 4 heel pressure ulcer and a suprapubic catheter, on enhanced barrier precautions, received wound care from an LVN who failed to wear a gown as required by the facility’s infection control policy for high-contact care. Another resident with diabetes, neuropathic bladder, frequent incontinence, and recurrent UTIs received peri-care from a CNA who did not perform hand hygiene between glove changes and touched bedding and clothing after glove removal without sanitizing hands. Staff interviews confirmed prior training on EBP, PPE, and hand hygiene, but revealed gaps in understanding and implementation, while leadership interviews and policy review showed expectations for gown and glove use under enhanced barrier precautions and for hand sanitizing between glove changes, although the written peri-care/hand washing policy lacked specific glove and interim hand hygiene steps.
A resident with dementia, major depressive disorder, and aggressive behaviors, including attempting to hit staff, struck a CNA in the face while the CNA was preparing to provide care. The CNA responded by hitting the resident in the head, despite facility policy prohibiting abuse and requiring protection of residents from abuse by staff. Subsequent assessment by an LVN documented discoloration to the resident’s forehead, possible jaw edema, and slight discoloration to the left upper ribs, and the resident later reported being "roughed up." Multiple staff interviews and the facility’s self-report confirmed that the CNA admitted to hitting the resident in retaliation.
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, labeling, and disposal, including multiple dry, refrigerated, and frozen items that were past best-by/use-by dates or lacked required labels such as item description, received date, and use-by date. Opened and prepared foods were stored without proper dating or identification, despite posted instructions requiring complete labeling. The DM, contracted dietary leadership, dietician, and ADMN all acknowledged that foods should be labeled and discarded per policy and that all residents ate from the kitchen, but the observed practices did not match these stated expectations or the facility’s written storage policies and the FDA Food Code.
A resident with severe cognitive impairment, multiple complex diagnoses (including pneumonia, CKD stage 4, MRSA pneumonia, malnutrition), dysphagia, and a mechanically altered diet did not have a comprehensive, person-centered care plan reflecting her evolving medical and dietary needs. The written care plan addressed only pressure ulcer risk and antibiotic therapy and omitted dysphagia, aspiration risk, supervision during meals, respiratory issues, pneumonia treatment, and textured diet/aspiration precautions ordered after hospitalizations. Interviews with the RNC, DON, and MDS nurse showed that although facility policy and practice required acute and updated care plans after readmissions and condition changes, staffing gaps in the MDS department and failure to complete acute care plans and updates led to the resident’s repeated hospitalizations, diet changes, and therapy needs not being incorporated into the care plan.
Surveyors found that the facility failed to create and implement comprehensive, person-centered care plans with measurable goals and timeframes to address fall and safety risks for three residents. One resident with Alzheimer’s disease, severe cognitive impairment, muscle weakness, and unsteadiness had multiple documented falls, yet his care plan contained only generic fall-risk statements without individualized fall interventions. Another cognitively intact resident with reduced mobility and a history of numerous falls had a care plan that did not include a person-centered fall-prevention plan. A third resident with repeated falls, obesity, muscle weakness, and moderate cognitive impairment experienced dozens of falls over a year, but her care plan remained limited to general fall-risk factors and assistance needs, without tailored, measurable strategies to reduce falls.
Failure to Use Ordered Transfer Aids Resulting in Resident Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents, specifically for one resident. The resident was a 78-year-old female with diagnoses including muscle weakness, unsteadiness of feet, lack of coordination, convulsions, osteoporosis, and a history of falls. Her MDS showed moderate cognitive impairment and a need for partial/moderate assistance with sit-to-stand and chair/bed-to-chair transfers. She was identified as high risk for falls, and the NP had ordered strict fall precautions due to impaired balance. Despite these risk factors, her comprehensive care plans only generally stated that she would receive assistance with transfers and ambulation and would use adaptive equipment such as transfer aids, but they did not specify the exact mode of transfer or required transfer device. There was no physician order detailing how she should be transferred. On the day of the incident, CNA A attempted to transfer the resident from bed to wheelchair without using any transfer aid such as a gait belt or sit-to-stand lift. Multiple staff interviews confirmed that the resident’s mode of transfer had been changed from stand-and-pivot to use of a sit-to-stand mechanical lift due to weakness, and that staff, including CNA A, were aware of this recommendation and had previously used the sit-to-stand with the resident. CNA A acknowledged knowing the resident was a sit-to-stand transfer and admitted she did not use the sit-to-stand on the day of the fall. RN B and the Weekend Supervisor both stated that if the resident was a one-person assist, a gait belt should have been used, and that transfer aids such as gait belts and mechanical lifts were expected for safety. RN B reported seeing the gait belt hanging on the wall unused when she entered the room after the incident. During the transfer, the resident lost her balance; staff reported that one of her knees gave out and she ended up kneeling on the floor beside the bed, with her upper body leaning on the bed. The resident complained of severe left hip pain rated 10/10 and requested to be sent to the hospital. She later reported that CNA A did not use a gait belt or a machine, while other CNAs did use a machine when transferring her. The DON and other staff confirmed that prior to the incident the resident was considered a one-person assist and that staff were supposed to use a gait belt and, if ordered, the sit-to-stand lift. The DON also acknowledged that therapy had recommended changing the resident’s mode of transfer to sit-to-stand and that she failed to follow up on whether this recommendation was finalized and implemented. There was no documentation that the resident refused the sit-to-stand prior to the fall. The combination of an unclear, nonspecific care plan, lack of a specific transfer order, failure to follow therapy’s transfer recommendations, and CNA A’s failure to use the required transfer aid during the transfer led to the fall and subsequent left hip fracture. The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents constituted noncompliance with F689 and resulted in an Immediate Jeopardy situation. The incident showed that the resident, who had multiple fall and fracture risk factors and was on strict fall precautions, was transferred without the prescribed or expected transfer aids, and that the facility had not ensured that the care plan and medical record clearly and specifically directed staff on the resident’s required mode of transfer. Interviews with multiple staff members revealed inconsistent understanding and implementation of the resident’s transfer status and highlighted that, at the time of the incident, the resident’s transfer needs were not consistently communicated or followed, directly contributing to the accident.
Removal Plan
- Resident #1 evaluated by nursing staff
- Resident #1 care plan updated to reflect current transfer status (requires sit-to-stand lift)
- Order placed in the electronic medical record for mechanical lift transfers for Resident #1
- Physical Therapy referral placed in the electronic medical record for evaluation and treatment for Resident #1
- All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy prior to working their next shift (including telephone education for absent staff)
- All new hires and agency staff to receive Safe Resident Handling/Transfers policy education before providing resident care
- 1:1 education provided to the Director of Nursing on following therapy recommendations for resident transfers and discussing transfer needs in clinical meetings and Standards of Care meetings
- DON/designee reassessed all residents using the Fall Risk Assessment Tool
- MDS/MOS nurse ensured all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans
- MDS/MOS nurse ensured added safety measures/interventions were reflected in both electronic and paper medical records so CNAs had access
- DON/designee instructed CNAs to review the updated paper medical record prior to their next shift
- Audit of all residents requiring assistance with transfers to ensure accuracy of transfer status and updated care plans
- Audit of all therapy recommendations to ensure they were reviewed and followed
- Safe Resident Handling/Transfers policy reviewed
- DON/designee to audit new admissions daily to ensure Fall Risk Assessment completion and that risk factors, safety measures, and resident-specific interventions are reflected on the care plan and updated on the Kardex
- Regional Nurse Consultant to review all falls within 72 hours to ensure an RCA is conducted and resident-specific interventions are reflected in the care plan and updated in paper/electronic care plans
- DON/designee to review all falls at the daily stand-up meeting with the IDT to ensure appropriate fall interventions are implemented, the care plan is reviewed/revised, and the Kardex is updated
- Interdisciplinary team to review all audit results in QAPI with additional training provided if trends are identified
- Medical Director notified of the deficient practice/Immediate Jeopardy and the Plan of Removal
Inaccurate MDS Coding of Mechanical Lift Use for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that comprehensive MDS assessments accurately reflected the use of mechanical lifts for eight residents out of twenty-nine reviewed. For multiple residents with diagnoses such as muscle weakness, unsteadiness of feet, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting, the corresponding Comprehensive MDS Assessments did not indicate that mechanical lifts or sit-to-stand devices were being used, despite other evidence that these devices were part of their care. The MDS Nurse stated she did not code the use of mechanical lifts because she did not see physician orders for these devices, even though she acknowledged that the MDS is a tool to identify resident care needs and provide an overall picture of the resident. For one resident with moderate cognitive impairment and a history of falls, the Comprehensive MDS Assessment did not show mechanical lift use, and the care plan referenced adaptive equipment for ADLs without specifying the transfer aid. The resident reported that some staff transferred her using a machine and that she had used it the previous year. Another cognitively intact resident with muscle weakness and lack of coordination had a care plan intervention specifying assistance with transfers via mechanical lift as needed, but the MDS did not reflect mechanical lift use and there was no physician order for a mechanical lift. A third cognitively intact resident with similar diagnoses had a care plan directing transfer with a Hoyer lift to a wheelchair; however, the MDS did not indicate mechanical lift use and there was no physician order, even though the resident described being transferred with a machine and surveyors observed CNAs using a Hoyer lift and sling to transfer her. Additional residents with severe or moderate cognitive impairment, repeated falls, muscle weakness, unsteadiness of feet, lack of coordination, multiple sclerosis, contractures, and muscle wasting also had Comprehensive MDS Assessments that did not indicate mechanical lift or sit-to-stand use. Their care plans either did not specify the type of transfer aid or did not include Hoyer lift interventions, and physician orders for mechanical lifts or sit-to-stand devices were absent. One resident reported beginning to use a sit-to-stand device when his legs became weaker, and surveyors observed CNAs transferring him with a sit-to-stand machine, yet his MDS did not reflect this mode of transfer and there was no corresponding order. The facility’s written policy on comprehensive assessment required gathering relevant information from multiple sources, including observation, physical assessment, and resident interview, to conduct comprehensive assessments and develop person-centered care plans, but the assessments reviewed did not accurately capture the residents’ actual transfer methods involving mechanical lifts.
Failure to Care Plan and Order Specific Mechanical Lift Transfer Modes
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans that included specific, measurable objectives and timeframes for residents’ transfer needs, particularly the use of mechanical lifts. For multiple residents with diagnoses such as muscle weakness, unsteadiness of feet, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting, the comprehensive MDS assessments did not indicate the use of mechanical lifts. Despite these conditions and histories of falls, the residents’ care plans either generically referenced adaptive equipment or assistance with transfers without specifying the type of transfer aid or mechanical lift to be used. For one resident with moderate cognitive impairment and a history of falls, the care plan identified fall risk and referenced adaptive equipment but did not specify the transfer aid, and there was no physician order for a sit-to-stand device, even though the resident reported that some staff transferred her using a machine. Another resident with severe cognitive impairment and lower extremity weakness had a care plan that stated he would be assisted with transfers and use adaptive equipment, but it did not identify the specific transfer aid, and there was no physician order for a sit-to-stand, despite the resident stating he began using a sit-to-stand device when his legs became weaker. Surveyor observation confirmed CNAs using a sit-to-stand machine to transfer this resident to a wheelchair. Additional residents with severe or moderate cognitive impairment, repeated falls, muscle weakness, lack of coordination, multiple sclerosis, contractures, and muscle wasting were not care planned for the specific use of Hoyer lifts or other mechanical lifts, and their physician orders did not include these devices. Their care plans referenced varying levels of staff assistance for ADLs and the use of adaptive equipment but did not identify the specific transfer mode or mechanical lift in use. Facility policy required comprehensive person-centered care plans with measurable objectives and timeframes to meet residents’ needs as identified in the comprehensive assessment, but the care plans for these residents did not reflect the specific transfer needs or mechanical lift use that was being provided.
Failure to Provide Privacy Curtains for Multiple Bed Spaces
Penalty
Summary
The deficiency involves the facility’s failure to ensure full visual privacy for residents in three of twelve rooms reviewed, specifically the B beds in rooms identified in the report. Surveyor observations showed that one room lacked a privacy curtain for Bed B and did not even have a ceiling track installed to allow a curtain to be hung. In another room, the privacy curtain for Bed B had been repositioned over the window because the window did not have its own curtain, leaving the end of Bed B exposed. A third room had a ceiling track installed for a privacy curtain for Bed B, but no curtain was present. The report states that this failure placed residents at risk for no visual privacy during care, which could cause decreased feelings of self-worth. Multiple staff interviews confirmed that privacy and dignity were recognized as important aspects of resident care. The Activity Director, LVN, CNAs, and RN all stated that residents had a right to privacy, that the facility was the residents’ home, and that protecting privacy was important for dignity, self-esteem, comfort, and helping residents feel safe and valued. CNAs reported that requests for repairs, including hanging curtains, were placed in a maintenance logbook, and one CNA stated she had not noticed the lack of curtains on the 100 Hall and that maintenance was responsible for hanging curtains. An attempted interview with the Director of Plant Operations was unsuccessful. Review of the facility’s “Quality of Life – Homelike Environment” policy from May 2017 reflected that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Protect Resident Dignity and Privacy in Public Areas
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity by allowing two residents to remain exposed in public areas. One resident, an elderly female with dementia, severe cognitive impairment (BIMS score of 7), wheelchair use, and total dependence on staff for ADLs including lower body dressing, was observed in the main lobby in a reclining chair with a blanket moved to the side and no clothing from the waist down, leaving her brief exposed. When asked if she wanted to cover up or wear pants, she declined. Later the same day, she was observed in the dining room eating her noon meal in the same reclining chair with her left leg exposed up to her hip and her brief visible, while other residents were in the immediate area. Her care plan documented an ADL self-care deficit and bowel and bladder incontinence. A second resident, an elderly male with kidney failure, complications of an indwelling urinary catheter, Parkinson’s disease, moderate cognitive impairment (BIMS score of 9), and dependence on staff for most ADLs, was observed eating his noon meal in the main dining room with his urine collection bag hanging from his wheelchair without a privacy cover. His care plan documented bladder incontinence, an indwelling catheter, and an ADL self-care deficit. Multiple staff interviews, including with the Activity Director, LVN, CNAs, RN, and ADON, confirmed their understanding that residents’ privacy, dignity, and self-esteem should be protected, that residents should not be exposed to others, and that the facility is the residents’ home. The ADON stated she was not aware that the male resident had been out without a privacy cover on his urine collection bag or that the female resident had exposed herself by pulling off her blanket, and stated the female resident should have been fully dressed. The facility’s Resident Rights policy required employees to treat all residents with kindness, respect, and dignity and affirmed residents’ rights to a dignified existence and to be treated with respect, kindness, and dignity.
Failure to Follow PPE and Hand Hygiene Protocols During Wound Care and Peri-Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices for two residents during observed care. For one resident, a female with hemiplegia, hypotension, dementia, and a stage 4 pressure ulcer on the left heel, the care plan and orders documented that she was on enhanced barrier precautions for a suprapubic catheter and heel wound, and that wound care required daily dressing changes. During an observation of wound care, the LVN performed the procedure without donning a gown, despite the facility’s infection control policy requiring gown and gloves for high-contact resident care activities under enhanced barrier precautions. In an interview, the LVN acknowledged having been trained on evidence-based practice (EBP) protocols about a month earlier, stated that nurses were responsible for following the EBP policy, and admitted she forgot to wear a gown and understood that not following EBP could lead to cross contamination and passing infection to other residents. For the second resident, a 78-year-old female with type 2 diabetes mellitus, repeated falls, neuropathic bladder, frequent urinary incontinence, and a history of recurrent UTIs treated with prophylactic antibiotics, staff were responsible per the care plan for checking for incontinence and washing, rinsing, and drying soiled areas. During an observation of peri-care, CNA A did not perform hand hygiene between glove changes while cleaning the resident’s front perineal area and before moving to the back (anal) area. After removing his gloves, CNA A touched the resident’s bedding and clothing while assisting with repositioning without sanitizing his hands. CNA B assisted by handing wipes during the peri-care. In interviews, CNA A reported receiving in-service training on hand hygiene and peri-care about a month earlier but stated he was not aware of the need to sanitize hands between glove changes during peri-care and believed washing before and after the procedure was sufficient; he acknowledged that improper hand hygiene could cause cross contamination. CNA B stated she had received similar training a few months earlier and had been instructed to sanitize hands between glove changes during peri-care. The ADON, serving as Infection Preventionist, the DON, and the Administrator all stated that staff were trained to wear gowns and gloves for high-contact care under enhanced barrier precautions and to sanitize hands between glove changes during peri-care, and that they were responsible for monitoring staff compliance. Review of the facility’s peri-care and hand washing policy indicated it addressed hand cleansing to prevent transmission of infectious material but did not specify glove use or hand sanitizing between glove changes, while the infection control policy on enhanced barrier protection required gown and gloves during high-contact resident care activities for residents with wounds and indwelling devices.
Failure to Protect a Cognitively Impaired Resident From Physical Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a staff member. The resident was an elderly male with major depressive disorder, dementia, hypertension, and anxiety disorder, care planned for impaired cognitive function, fall risk, and aggressive behaviors such as throwing objects and attempting to hit staff. His BIMS score of 3 indicated severe cognitive deficit. On the day of the incident, a nursing assistant (NA B) was providing care and preparing to lock the resident’s wheelchair to get him ready to be changed when the resident struck NA B in the face. According to NA B’s written statement, she then hit the resident back in the head “out of reflexes,” in direct violation of the facility’s abuse prevention policy, which states residents have the right to be free from abuse and that the facility must protect residents from abuse by anyone, including staff. Following the incident, staff interviews and documentation confirmed that NA B admitted to hitting the resident in response to being hit. CNA D reported that NA B came out of the room talking about what had happened and appeared to be in shock, and CNA C reported hearing NA B yell, “Don’t do that!” before being told by NA B that the resident had hit her and she hit him back. The administrator stated that NA B disclosed the incident after being removed from resident care, and the HR representative reported that NA B explained her behavior by referencing how she was taught to respond when hit. A progress note documented that an LVN assessed the resident and noted light discoloration to the forehead, possible edema to the jaw area, and slight discoloration to the left upper ribs, with x‑rays ordered of the skull, jaw, and ribs for precautionary evaluation. The facility’s self-report indicated that the resident stated he was “roughed up” and that NA B admitted to hitting him in the head.
Improper Food Storage, Labeling, and Disposal in Kitchen Food Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and disposal of food items in the kitchen. During a kitchen observation, they found multiple dry storage items that were not handled according to facility policy and professional standards, including an opened bag of chips in a plastic bag labeled with a use-by date that was 11 days past, an unopened bag of hamburger buns with no received date, use-by date, or item description, and an opened box of flour tortillas with several bags bearing a best-by date that had already passed. The facility’s posted instructions in the kitchen stated that everything must have a label with received date, open date, and use-by date, but these requirements were not consistently followed. In the refrigerated storage, surveyors observed additional issues, including two cartons of heavy whipping cream with best-by dates that had passed, two bags of corn tortillas with best-by dates that were more than a month past, and an opened bag of shredded white cheese labeled only with a date and no use-by date or item description. They also found an opened container of pimento spread with no received date and an illegible use-by date, an unopened bag of what appeared to be hot dogs with only a handwritten date and no use-by date or item description, and two containers of prepared food (one in a see-through plastic container and one in a metal tin) without preparation dates, use-by dates, or item descriptions. In the freezers, surveyors found an opened bag of what appeared to be french fries that was not sealed and lacked any delivery date, use-by date, or item description, and three unopened bags of what appeared to be garlic toast labeled only with a date and no use-by date or item description. Interviews with facility and contracted dietary staff confirmed that these practices did not align with the facility’s policies and expectations. The dietary manager stated that all food items stored outside their original containers should have a received date, item description, and, when applicable, a use-by date, and that items should not be stored past their best-by dates. The contracted Director of Operations for dietary services and the dietitian both stated that foods should be labeled with descriptions and expiration or use-by dates when stored outside original packaging and discarded after those dates, and that the dietary manager was responsible for monitoring labeling and storage. The administrator stated that all residents ate from the kitchen, that dietary services were contracted, and that his expectation was that foods be stored, labeled, and discarded per policy. Facility policies on dry goods and cold food storage required that all goods be appropriately date-labeled and that foods be wrapped, covered, or contained within labeled and dated packages or containers, and the FDA Food Code was cited regarding required food labeling and consumption or disposal of refrigerated foods by their expiration date.
Failure to Maintain Comprehensive, Person-Centered Care Plan After Hospitalizations and Diet Changes
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, an elderly female, had numerous diagnoses including lobar pneumonia, acute kidney failure, gout, mononeuropathy, diabetes, malignant neoplasm, metabolic encephalopathy, anemia, stage 4 chronic kidney disease, MRSA pneumonia, and malnutrition. Her 5-day admission MDS showed a BIMS score of 5 indicating severe cognitive impairment, range of motion impairment, wheelchair use, need for supervision or touching assistance with eating, and a mechanically altered/therapeutic diet with high-risk medications. She also had orders for skilled speech therapy for cognitive-linguistic deficits and dysphagia management, and a speech-language pathology screening documented signs of swallowing impairment and the need for a mechanically altered diet. Despite these identified needs, record review showed that the resident’s care plan contained only two focus areas: pressure ulcer risk and antibiotic therapy, initiated in December. The care plan did not address dysphagia, aspiration risk, supervision during meals, respiratory issues, or treatments related to pneumonia, nor did it reflect her textured diet orders, aspiration precautions, or additional antibiotic treatment following hospitalization for pneumonia and subsequent readmission. Physician orders documented a low-concentrated sweets/no added salt diet with ground texture and thin liquids, and nephrology notes documented a hospitalization for right lower lobe pneumonia with antibiotic treatment and an ordered textured diet, but these changes and risks were not incorporated into the care plan. Interviews with the RNC, DON, and the MDS nurse revealed that the MDS nurse was responsible for initial care plan development and updates, and that acute care plans were expected to be completed immediately upon readmission with new conditions or concerns. The RNC and DON stated that the resident had not been continuously in the facility for 21 days to trigger a comprehensive care plan and that during the relevant period there was no MDS nurse for about a month, resulting in a backlog despite some corporate assistance. The MDS nurse described the expected process for post-hospital discharge review, including morning meetings to capture changes such as hospitalizations, diet changes, therapy referrals, and emerging risks, and confirmed that repeat hospitalizations, pneumonia, swallowing risks, diet downgrades, antibiotic use, and decline should be reflected in the care plan. The facility’s written policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident and mandated IDT review and updates with significant changes in condition and upon readmission, but these requirements were not met for this resident.
Failure to Develop Person-Centered Fall Prevention Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address fall and safety risks for three residents. For a male resident with Alzheimer’s disease, muscle weakness, unsteadiness on his feet, and a severely impaired BIMS score of 6, the MDS identified him as at risk for falls. His care plan, last revised on 1/06/2026, noted fall risk related to unsteady gait, decreased balance, medications, poor safety awareness, use of a mobility device, and need for assistance with transfers, but lacked person-centered fall interventions despite documented falls on 3/23/2024, 7/28/2024, and 1/13/2026. A female resident with cellulitis of the abdominal wall, late-onset Alzheimer’s disease, reduced mobility, and need for assistance with personal care had an MDS BIMS score of 13, indicating intact cognition, and was coded as a fall risk. Her care plan, also last revised on 1/06/2026, similarly identified generic fall risk factors and assistance needs but did not include a person-centered plan to address her falls, despite 17 falls between 8/13/2025 and 12/27/2025. Another female resident with sepsis, repeated falls, obesity, and muscle weakness had an MDS BIMS score of 8, indicating moderate cognitive impairment, and was coded as a fall risk. Her care plan, last revised on 1/06/2026, documented fall risk factors and assistance with transfers but did not provide individualized, measurable fall-prevention strategies, even though she experienced 45 falls over the prior 12 months.
Some of the Latest Corrective Actions taken by Facilities in Texas
- Sent communications to all skilled-nursing family members regarding the facility policy on outside medications and scheduled monthly reminders for the next three months to reinforce compliance with the outside-medication policy (K - F0740 - TX)
- Added the facility policy on outside medications to the admission packet for all new residents to prevent unauthorized medications from being brought into resident rooms (K - F0740 - TX)
- Incorporated standard operating procedures for handling unauthorized outside medications into ongoing new-hire orientation for licensed nurses and nurse managers to standardize required actions when outside medications were identified (J - F0656 - TX)
- Trained the Staff Development Coordinator on the policy for comprehensive person-centered care plans addressing mental health needs with measurable objectives, timeframes, and interventions (J - F0656 - TX)
- Educated leadership and licensed nurses on the facility policy for comprehensive person-centered care plans including measurable objectives, timeframes, and interventions addressing mental health needs, with annual retraining and documented completion requirements (J - F0656 - TX)
- Established ongoing wellness interviews using PHQ-9 questions (including staff-observation PHQ-9 for non-interviewable residents) with immediate intervention triggers for concerning responses (provider notification, psychiatric referral, care plan updates, and safety measures) (K - F0740 - TX) (J - F0656 - TX)
- Implemented review of identified at-risk residents during clinical meetings to monitor for changes in depressive symptoms and/or suicidal ideations (J - F0656 - TX)
- Implemented ongoing audits of care plans and new admissions to validate PHQ-9 completion and that care plans included measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs, with findings reviewed in QAPI meetings to determine additional audits and education (J - F0656 - TX)
Failure to Provide Necessary Behavioral Health Services to Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with significant behavioral health needs received necessary behavioral health care and services in accordance with her assessment and care plan. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, vascular dementia with psychotic disturbance, anxiety disorder, and epilepsy. Her MDS showed a BIMS score of 14, indicating little to no cognitive impairment, and documented depressive symptoms several days in the prior two weeks. Her care plan identified depression related to a family member’s death, lack of closure, perceived lack of money, limited family visits, and feeling confined to her room, with signs including poor appetite, trouble sleeping at night, and sleeping in. The care plan also documented suicidal ideations and interventions such as listening, providing comfort, and communication to promote mental and psychological well-being, with the social worker identified as her mental health professional. The resident had a history of suicidal behavior and ideation while at the facility. Progress notes documented that on one occasion she wrapped a draw sheet around her neck, stated she wanted to die and join her deceased family member, and an order was obtained to keep a close eye on her every 15 minutes. On another occasion, she approached a nurse stating she was feeling suicidal, was looking for a bottle of pills to take, and did not care anymore; she also told police she would use a light bulb to cut herself, and she was transported to a hospital. The care plan reflected prior hospitalizations at behavioral health facilities, and interviews with the DON, Administrator, and family confirmed multiple inpatient behavioral health stays and a prior suicide attempt at the facility involving a bedsheet around her neck. Despite this history, record review of the electronic health record on the date of her death showed no evidence that she was receiving behavioral health services at the time of her suicide. In the period leading up to the fatal event, staff continued to observe depressive symptoms and suicidal ideations. A social worker note documented that the resident stated she wanted to die, felt she was a disappointment, did not want to do anything, and did not want to eat, though she denied a plan and said she would not harm herself; the physician was notified, and the resident had a private caregiver with her daily from 2:00 PM to 4:00 PM. An LVN reported that for months after the resident’s third behavioral health facility stay, the resident continued to express suicidal ideations, slept all day, and often said she was sad; the LVN stated she reported these ongoing suicidal ideations to the medical director and DON, but the resident was not sent back to a behavioral health center. The facility instead increased activities and relied on counseling by the social worker, although the social worker reported that for the last six months the resident refused to speak with her and was not seeing another therapist. On the day before the resident’s death, an LVN documented that the resident produced an unopened bottle of diphenhydramine (Benadryl) from her drawer, and the nurse locked it in the medication cabinet and administered a provider-ordered dose; the next morning the resident was found unresponsive with pink emesis and two diphenhydramine bottles at the bedside, one almost empty, and hospital records indicated concern for an intentional overdose. Interviews and record review confirmed that, at the time of this lethal ingestion, the resident was not receiving behavioral health services despite her ongoing suicidal ideations and documented history of depression and prior suicide attempts. The facility’s own suicide threats policy required immediate reporting of suicide threats to a licensed nurse, leadership, and campus dispatch, continuous staff presence with the resident until a licensed nurse or provider arrived, and interdisciplinary assessment and care plan revision after such incidents. While some prior suicidal episodes resulted in hospital transfers and temporary 1:1 sitters, the ongoing expressions of suicidal ideation over several months after the last behavioral health discharge were not accompanied by documented behavioral health services or further inpatient evaluation. Staff interviews revealed that personal sitters and CNAs were aware of the resident’s depression and sleep patterns but did not consistently report suicidal ideations to the social worker, who stated she was not informed of continued suicidal ideations. The combination of a known history of suicide attempts, repeated suicidal statements, refusal of counseling, and lack of active behavioral health services at the time of the event formed the basis of the deficiency, culminating in the resident’s ingestion of a lethal dose of diphenhydramine and subsequent death.
Removal Plan
- Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
- Nursing staff completed a 100% room sweep of all skilled nursing residents' rooms to ensure no outside or unauthorized medications were present in residents' rooms.
- Send a communication to all family members of skilled nursing regarding the facility medication policy for outside medications and send monthly for the next three months.
- Add communication on the facility policy for outside medications to the admission packet for all new residents.
- Director of Nursing initiated interviews with all staff that cared for Resident #1 in the past week to confirm whether any signs or changes in resident mood or suicidal ideations were observed.
- Reinforce that suicide threats are to be taken seriously and immediately reported to the licensed nurse, clinical leaders, campus dispatch and/or administration.
- Staff must immediately report suicidal threats to the licensed nurse.
- The licensed nurse must immediately notify CC Leadership on Call and campus dispatch.
- Administration/nursing administration with the medical provider will determine appropriate interventions including potential 1:1 supervision and potential need for emergency/acute care evaluation/treatment.
- The interdisciplinary team will assess actions/expressions as soon as possible to determine needed interventions and revise care/service plans.
- Documentation must be recorded in the medical record and an incident report completed.
- Director of Nursing or designees will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for immediate signs of depression, depression symptoms, and/or thoughts of self-harm.
- Residents with concerning responses will have appropriate interventions implemented immediately including provider notification and psychiatric referral.
Failure to Provide Effective Hospice Pain Management for Terminal Cancer Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management to a hospice resident with end‑stage metastatic cancer to the breast, liver, bone, and intrahepatic bile ducts. On admission for respite care, the resident was confused, disoriented, crying, and restless, and an initial pain assessment documented non‑verbal indicators of pain, including loud moaning or groaning, crying, facial grimacing, tense body language, and a pain score of 6, with an acceptable pain level of 0. The resident was started on morphine sulfate oral solution with an order for 0.25 mL every two hours PRN for shortness of breath and pain, later changed to a routine schedule and then back to PRN with a range dose of 0.25–1.0 mL every hour. Despite these orders, the facility did not complete a finished baseline care plan or comprehensive care plan for the resident, and the existing care plan only addressed impaired communication without specific pain management interventions. From admission through the identified period, the resident exhibited persistent and severe non‑verbal signs of pain, including thrashing and writhing in bed, crying, moaning, groaning, screaming during incontinent care, facial grimacing, clenched jaw, and inability to be consoled or respond to questions. Observations on multiple occasions showed the resident becoming more distressed with movement and care. CNAs reported that the resident was always crying, screaming during changes, restless, and grimacing, and they notified nursing staff of these signs. Family members also reported that the resident had been in pain every time they visited, that she had stage 4 cancer, and that she had not been comfortable since arriving at the facility. One family member stated staff only glanced into the room rather than performing full assessments and expressed that the resident’s pain was not being managed. Nursing staff acknowledged that the resident’s behaviors indicated pain and that the morphine doses being given were not effective. The LVN caring for the resident stated that the current morphine order allowed 0.25–1.0 mL every hour PRN, but he consistently administered only 0.25 mL, later 0.5 mL, despite ongoing severe pain behaviors, and documented these doses only in the narcotic log rather than on the MAR. He reported assessing the resident’s pain every 30–60 minutes but did not chart these assessments, and the EHR contained no pain assessments during this period. The MAR showed no breakthrough or long‑acting pain medications, and there was no documentation that the physician or hospice was notified when the resident displayed uncontrolled pain. The DON and hospice staff confirmed that the resident’s pain was severe and ongoing, that the morphine order had been changed to PRN partly in response to a non‑POA friend’s concerns about sedation and eating, and that staff and hospice had been influenced by this friend’s wishes rather than consistently prioritizing the resident’s comfort. These actions and omissions resulted in the resident experiencing prolonged, uncontrolled pain and led surveyors to identify immediate jeopardy related to pain management. The facility’s own pain management policy required assessment for pain upon admission and with changes in condition, establishment of pain management goals, individualized interventions, ongoing monitoring of response to pharmacologic and non‑pharmacologic measures, and reporting to the physician of patient response to interventions. The hospice coordination policy required a coordinated plan of care, directives for managing pain and uncomfortable symptoms, monitoring and evaluation of the resident’s response to hospice care plans, and immediate communication with hospice and the attending physician regarding significant changes or emergent situations. In this case, the facility did not complete or implement a comprehensive, individualized pain management plan, did not consistently assess and document pain or reassess after interventions, did not fully utilize the ordered morphine range to address uncontrolled pain, and did not document timely escalation to hospice or the physician when pain remained severe. These failures, in the context of the resident’s terminal cancer and clear non‑verbal signs of excruciating pain, constituted the cited deficiency in pain management.
Removal Plan
- Charge Nurse/DON/designee assessed the resident’s pain using an appropriate tool (0-10 scale if able; PAINAD/non-verbal tool if unable) and documented signs/symptoms and current comfort level.
- Facility contacted the hospice nurse and attending/medical provider to report uncontrolled pain episodes and frequency of distress behaviors.
- Facility obtained clarified, complete medication orders from prescriber/hospice that include clear administration parameters (e.g., which dose to give under which conditions) and documented these orders per policy.
- Facility updated the care plan to reflect end-of-life comfort needs, pain assessment frequency, medication administration/reassessment expectations, and hospice coordination.
- Facility implemented enhanced monitoring until pain was controlled, including pain checks and comfort rounds at least hourly, with reassessment after each intervention and documentation of effectiveness.
- DON/designee ran a list of all residents on hospice and all residents with active opioid PRN range orders and/or recent pain complaints.
- For each identified resident, a licensed nurse/designee audited for complete parameters on PRN/range orders (no range without direction), pain assessment and reassessment documentation after PRN administration, evidence of provider/hospice notification for uncontrolled pain, and care plan alignment with pain management needs.
- Any orders lacking parameters were held for clarification; the facility contacted the provider/hospice promptly and residents were assessed and managed per hospice/provider direction.
- Facility implemented a requirement to not accept or implement range/variable dose opioid orders without written parameters from prescriber/hospice (dose selection criteria, frequency limits, reassessment expectations, and hold criteria).
- Orders missing parameters triggered an automatic provider/hospice clarification call and documented follow-up.
- Facility implemented an uncontrolled pain escalation pathway requiring staff to notify hospice/provider when pain is not relieved or distress behaviors persist, using defined escalation triggers (e.g., repeated PRN use, persistent severe pain behaviors, frequent crying/screaming).
- For hospice residents, facility implemented use of a Hospice Symptom Escalation Call Log to document time of call, who was contacted, response received, and new orders.
- Facility implemented documentation standards requiring pain documentation every shift and with any complaint/behavior suggestive of pain, before PRN administration (baseline), reassessment after medication/intervention within policy timeframe, documentation of effectiveness, and documentation of escalation if ineffective.
- Facility provided staff education/competency training for all licensed nurses (and individualized education for those who missed the in-service) on pain assessment including non-verbal tools, end-of-life comfort care expectations and SNF/hospice coordination, PRN opioid documentation and reassessment standards, and clarifying incomplete orders/range dose parameters, with sign-in sheets and a post-test prior to assuming duties.
- Facility implemented audits/monitoring using a Pain Management & Hospice Coordination Audit tool to monitor PRN opioid/range order parameters, pain assessment documentation, reassessment after each PRN, hospice/provider notification when pain uncontrolled, and care plan alignment with pain/hospice involvement.
- Facility set audit frequency to weekly for 4 weeks, then monthly for 2 months, then quarterly, with DON/ADON/designee and unit managers responsible for follow-up and results reviewed in QAPI with trends/actions documented.
- QAPI committee provided oversight to review audit results, identify patterns (e.g., missing parameters, missed reassessments, delays calling hospice/provider), and implement additional actions (targeted re-education, disciplinary action if warranted, EMR prompts, staffing workflow changes).
Failure to Use Ordered Transfer Aids Resulting in Resident Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents, specifically for one resident. The resident was a 78-year-old female with diagnoses including muscle weakness, unsteadiness of feet, lack of coordination, convulsions, osteoporosis, and a history of falls. Her MDS showed moderate cognitive impairment and a need for partial/moderate assistance with sit-to-stand and chair/bed-to-chair transfers. She was identified as high risk for falls, and the NP had ordered strict fall precautions due to impaired balance. Despite these risk factors, her comprehensive care plans only generally stated that she would receive assistance with transfers and ambulation and would use adaptive equipment such as transfer aids, but they did not specify the exact mode of transfer or required transfer device. There was no physician order detailing how she should be transferred. On the day of the incident, CNA A attempted to transfer the resident from bed to wheelchair without using any transfer aid such as a gait belt or sit-to-stand lift. Multiple staff interviews confirmed that the resident’s mode of transfer had been changed from stand-and-pivot to use of a sit-to-stand mechanical lift due to weakness, and that staff, including CNA A, were aware of this recommendation and had previously used the sit-to-stand with the resident. CNA A acknowledged knowing the resident was a sit-to-stand transfer and admitted she did not use the sit-to-stand on the day of the fall. RN B and the Weekend Supervisor both stated that if the resident was a one-person assist, a gait belt should have been used, and that transfer aids such as gait belts and mechanical lifts were expected for safety. RN B reported seeing the gait belt hanging on the wall unused when she entered the room after the incident. During the transfer, the resident lost her balance; staff reported that one of her knees gave out and she ended up kneeling on the floor beside the bed, with her upper body leaning on the bed. The resident complained of severe left hip pain rated 10/10 and requested to be sent to the hospital. She later reported that CNA A did not use a gait belt or a machine, while other CNAs did use a machine when transferring her. The DON and other staff confirmed that prior to the incident the resident was considered a one-person assist and that staff were supposed to use a gait belt and, if ordered, the sit-to-stand lift. The DON also acknowledged that therapy had recommended changing the resident’s mode of transfer to sit-to-stand and that she failed to follow up on whether this recommendation was finalized and implemented. There was no documentation that the resident refused the sit-to-stand prior to the fall. The combination of an unclear, nonspecific care plan, lack of a specific transfer order, failure to follow therapy’s transfer recommendations, and CNA A’s failure to use the required transfer aid during the transfer led to the fall and subsequent left hip fracture. The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents constituted noncompliance with F689 and resulted in an Immediate Jeopardy situation. The incident showed that the resident, who had multiple fall and fracture risk factors and was on strict fall precautions, was transferred without the prescribed or expected transfer aids, and that the facility had not ensured that the care plan and medical record clearly and specifically directed staff on the resident’s required mode of transfer. Interviews with multiple staff members revealed inconsistent understanding and implementation of the resident’s transfer status and highlighted that, at the time of the incident, the resident’s transfer needs were not consistently communicated or followed, directly contributing to the accident.
Removal Plan
- Resident #1 evaluated by nursing staff
- Resident #1 care plan updated to reflect current transfer status (requires sit-to-stand lift)
- Order placed in the electronic medical record for mechanical lift transfers for Resident #1
- Physical Therapy referral placed in the electronic medical record for evaluation and treatment for Resident #1
- All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy prior to working their next shift (including telephone education for absent staff)
- All new hires and agency staff to receive Safe Resident Handling/Transfers policy education before providing resident care
- 1:1 education provided to the Director of Nursing on following therapy recommendations for resident transfers and discussing transfer needs in clinical meetings and Standards of Care meetings
- DON/designee reassessed all residents using the Fall Risk Assessment Tool
- MDS/MOS nurse ensured all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans
- MDS/MOS nurse ensured added safety measures/interventions were reflected in both electronic and paper medical records so CNAs had access
- DON/designee instructed CNAs to review the updated paper medical record prior to their next shift
- Audit of all residents requiring assistance with transfers to ensure accuracy of transfer status and updated care plans
- Audit of all therapy recommendations to ensure they were reviewed and followed
- Safe Resident Handling/Transfers policy reviewed
- DON/designee to audit new admissions daily to ensure Fall Risk Assessment completion and that risk factors, safety measures, and resident-specific interventions are reflected on the care plan and updated on the Kardex
- Regional Nurse Consultant to review all falls within 72 hours to ensure an RCA is conducted and resident-specific interventions are reflected in the care plan and updated in paper/electronic care plans
- DON/designee to review all falls at the daily stand-up meeting with the IDT to ensure appropriate fall interventions are implemented, the care plan is reviewed/revised, and the Kardex is updated
- Interdisciplinary team to review all audit results in QAPI with additional training provided if trends are identified
- Medical Director notified of the deficient practice/Immediate Jeopardy and the Plan of Removal
Failure to Respond to Resident’s Acute Respiratory Distress and Request for 911
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s expressed wishes during an acute change in condition. The resident involved was an older female with intact cognition (BIMS 15) and significant cardiac and renal comorbidities, including diastolic CHF, hypertension, paroxysmal atrial fibrillation, aortic stenosis, and end-stage renal disease on hemodialysis. Her care plan included monitoring and prompt reporting of significant changes in pulse, respirations, and blood pressure, administration of oxygen as ordered, and reporting signs and symptoms of malignant hypertension or other changes in condition. Prior oxygen saturation readings for this resident generally ranged from 91% to 98% on room air, and she had a PRN order for 2 L/min oxygen for shortness of breath. On the morning in question, video review showed the resident asking an LVN for oxygen, with the LVN acknowledging that the resident’s face looked flushed and obtaining vital signs, including an O2 saturation of 92% on room air. The resident repeatedly requested oxygen, became increasingly anxious, grimaced, breathed more heavily, and held her chest while stating she needed oxygen. The LVN left the room without immediately providing oxygen, and the resident’s distress continued, with difficulty talking and heavier breathing observed on video. Several minutes later, the LVN returned with oxygen, reported an O2 saturation of 97%, placed the oxygen on the resident, and then exited the room. The LVN later stated that the original oxygen tank in the room was not working, that the resident became flushed and more upset while waiting for oxygen, and that she did not call 911 or the physician, believing it was not necessary until she finished her assessment. Subsequently, the ADON entered the room while the resident was on 2 L/min oxygen and on the phone with a family member. Video review and nursing notes reflected that the resident was crying, repeatedly stating she could not breathe, and clearly asking for 911 to be called. The ADON questioned the resident, did not complete a documented assessment at that time, did not check O2 saturation, blood pressure, oxygen tank, or tubing as observed on video, and exited the room despite the resident’s continued complaints of shortness of breath and explicit requests for 911. When the ADON re-entered, the resident again stated she could not breathe and asked for 911; the ADON removed the resident’s phone from her chest and placed it out of her reach while the family member was still on the line, and again did not perform the assessments she later claimed in interview to have done. EMS arrived shortly thereafter, found the resident’s O2 saturation at 79% while on 2 L/min oxygen, and transported her to the hospital, where she was admitted with respiratory distress and pulmonary edema/volume overload. Facility leadership and staff interviews confirmed that facility expectations were to call 911 immediately when a resident complained of shortness of breath and requested 911, and that in this case staff did not honor the resident’s repeated requests or promptly recognize and act on the acute change in condition, leading to the identified deficiency under F684 (Quality of Care).
Removal Plan
- Resident #1 was discharged/transferred to the hospital.
- Investigation completed; ADON A received disciplinary action and one-on-one re-education.
- In-service completed for licensed nurses, nurse aides, and medication aides on honoring resident wishes when requesting 911; comprehension to be verified by post-test.
- Director of Nurses in-serviced by Clinical Service Director on honoring resident wishes when requesting 911, with a post-test.
- Interviewable residents to be interviewed to ensure staff are honoring their wishes; any identified concerns to be addressed immediately.
- Non-interviewable residents to be observed to ensure no change in condition is present; document on life satisfaction survey forms; administrator to review and address concerns immediately.
- Director of Nurses/designee to continue in-servicing newly hired staff (including PRN and agency, if utilized) during orientation on honoring residents’ wishes when wanting 911 called.
- Department heads to conduct daily rounds on assigned rooms (documented on life satisfaction survey forms) to interview/observe residents to ensure staff are honoring wishes (including requests to call 911); administrator to review documentation and address concerns immediately.
- Impromptu QAPI review of the plan of removal completed with the Medical Director; Medical Director reviewed and agreed with the plan.
Failure to Develop and Implement Comprehensive Care Plan for Resident With Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and specific interventions to address a resident’s identified suicidal ideations and significant mental health history. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, moderate vascular dementia with psychotic disturbance, anxiety disorder, and epilepsy. Her MDS showed a BIMS score of 14, indicating little to no cognitive impairment, and documented that she felt down, depressed, or hopeless on several days in the prior two weeks. The care plan noted prior behavioral health hospitalizations and that she would exhibit or express depression related to the death of a family member, lack of closure, financial concerns, limited family visits, and feeling confined to her room. Signs and symptoms of depression such as poor appetite and sleep disturbance were documented, and the care plan stated she would speak with the social worker if she needed counseling, identifying the social worker as her mental health professional. The resident’s care plan also documented that she had suicidal ideations, but the interventions listed were limited to listening and providing comfort when she was confused and agitated and communicating in a manner that promoted mental and psychological well-being. Despite multiple serious episodes indicating active suicidal ideation and behavior, the care plan was not revised to include more specific, measurable, and individualized interventions. Progress notes showed that on one occasion a CNA reported the resident had wrapped a draw sheet around her neck, stated she wanted to die and join her husband, and the MD ordered close observation every 15 minutes. On another occasion, the social worker documented that the resident stated she wanted to die, although she denied a plan and said she would not harm herself; the physician was notified and it was noted she had a caregiver with her for two hours daily. Later, the resident directly approached an LVN stating she was feeling suicidal, was looking for a bottle of pills to take, and did not care anymore; she also told police she would use a light bulb in her room to cut herself, leading to her being sent to the hospital. After these events, the care plan for suicidal ideation was not updated with detailed, resident-specific safety measures or clear, measurable objectives and timeframes. The DON stated that each department was responsible for its portion of the care plan, that the MDS coordinator was new and in training, and that there was no clinical manager for approximately two weeks, during which time he was responsible for care plans. The DON believed the existing interventions were appropriate and thought the resident was following them by attending activities and speaking with the social worker, so no additional interventions were added until after surveyor inquiry. The Administrator reported that the resident had been sent to behavioral health facilities multiple times and had previously been found with a bedsheet around her neck after a suicide pact with her husband, and that a 24-hour sitter had been reduced to two hours daily at the resident’s request. The Administrator and Medical Director both believed the resident had long-standing depression and had declined or refused some offered help, and the social worker reported that staff had not informed her of the resident’s continued suicidal ideations and that the resident had refused to speak with her for the last six months. Ultimately, EMS later found the resident unresponsive with an empty and a partially empty bottle of Benadryl at bedside, with multiple seizures en route to the hospital, and she was pronounced dead; family and EMS expressed concern that she may have intentionally overdosed, and surveyors determined that the facility had failed to develop and implement a comprehensive care plan with adequate, measurable interventions for her suicidal ideations.
Removal Plan
- Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
- Director of Nursing initiated interviews with all staff who cared for Resident #1 to determine whether any signs or changes in mood or suicidal ideations were observed.
- Director of Nursing (or designee) will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for depression symptoms and/or thoughts of self-harm; any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
- Social worker (or designee) will visit residents with concerning PHQ-9 responses and reassess ongoing visit needs.
- Social worker/nursing will conduct wellness interviews of non-interviewable residents using PHQ-9 questions #1 and #2 (staff observation); any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
- Regional Director of Clinical Operations completed a 100% audit of MDSs, confirming zero residents answered 'yes' to thoughts of being better off dead.
- Regional Director of Clinical Operations completed a 100% audit of MDSs with depressive symptoms.
- Director of Nursing (or designee) will conduct an audit of all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs identified in the comprehensive assessment; discrepancies will be corrected promptly.
- Director of Health Services Education and Training will train the Staff Development Coordinator (and/or designee) on the policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs.
- Staff Development Coordinator (and/or designee) will educate all leadership and licensed nurses on the facility policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs; training will be documented on a Management Training Roster maintained by NHA/HR; retraining will occur annually.
- Employees not trained due to absence, schedule rotation, or other factors will be removed from the schedule until required training is completed and documented.
- Standard operating procedures for handling unauthorized outside medications and required actions if noted in resident rooms will be incorporated into ongoing new-hire orientation for all licensed nurses and nurse managers.
- Identified at-risk residents will be reviewed during clinical meeting to assess for changes in depressive symptoms and/or suicidal ideations.
- Social worker (or designee) will perform wellness interviews using PHQ-9 questions #1, #2, and #9 with a randomized sample of residents; any identified concern will trigger immediate interventions including provider notification, psychiatric referral, care plan updates, and safety measures.
- Social worker will conduct wellness interviews of non-interviewable residents using staff-observation PHQ-9 questions #1 and #2.
- Director of Nursing (or designee) will conduct an audit of all newly admitted residents to confirm PHQ-9 assessments were completed and appropriate care plan interventions were implemented.
- Director of Nursing (or designee) will audit all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs; discrepancies will be corrected promptly.
- Director (or designee) will conduct an audit of all newly admitted residents to validate care plans include measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs to prevent serious harm or death.
- Audit findings will be reviewed during QAPI meetings; additional audits and education will be determined based on findings.
Failure to Prevent Elopement and Inadequate Supervision of High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for residents at risk of elopement, resulting in one resident leaving the building unsupervised and another high-risk resident being left outside alone. One resident, a female with type II diabetes mellitus, congestive heart failure, hypertension, acute kidney failure, major depression, and schizoaffective disorder, bipolar type, had a BIMS score of 8 indicating moderate cognitive impairment. Her care plan was updated after the incident to identify her as an elopement risk/wanderer. On the day of the elopement, she was last seen by an LVN shortly after 6:00 a.m. when she refused Accu-Checks and again around 7:40 a.m. near the breakfast room. A CNA reported that she delivered the resident’s breakfast tray around 7:50 a.m. and found the resident missing when she returned around 8:40 a.m. to pick up the tray. Video footage later showed this resident walking unattended in the front living room area at 8:15 a.m. and exiting the front door at 8:16 a.m. without staff supervision. The facility’s Administrator reported that the resident exited by using the door code and stated she had no prior knowledge that the resident knew the code, speculating that the resident must have obtained it from her boyfriend, another resident. The Administrator also stated that the master door code had not been changed since 2024 and that it had not been changed due to the perceived financial cost of updating all door codes. The facility’s elopement policy required prompt search and notification procedures once a resident was found missing, but the report documents that the resident was ultimately located offsite by a security guard at a local credit union approximately 0.5 miles away after crossing a busy frontage road, and was transported by EMS to a hospital ER, where she was found in an altered mental status. A second resident, a male with hemiplegia and hemiparesis affecting the left dominant side, dysphagia, and contractures of the left shoulder and elbow, had a BIMS score of 11, also indicating moderate cognitive impairment. His care plan included a focus that he often went outside and sat at the front entrance without alerting staff of his whereabouts, and he was identified as an elopement risk/wanderer with impaired safety awareness. Interventions included monitoring his whereabouts each shift and ensuring a functioning Wander Guard device. Despite this, observation showed this high elopement-risk resident sitting outside on the patio alone and unsupervised. The Administrator acknowledged that this resident knew the door code prior to her employment, that his knowledge of the code overrode the Wander Guard system, and that most Wander Guard devices in the facility were visual only and did not alarm. The Administrator stated there was no policy addressing residents with high elopement risk having knowledge of the master door code. These actions and inactions related to door code management, Wander Guard use, and supervision of residents at risk for elopement led to the identified deficiency under F689 for accidents and supervision.
Removal Plan
- Complete elopement risk assessments for all residents to ensure ongoing evaluation and implementation of appropriate preventive interventions.
- Implement a universal reset of the master door code to reduce the risk of unauthorized exit and elopement due to Resident #1's demonstrated knowledge of the door access code.
- Complete a facility-wide in-service for the Administrator and Maintenance Director on door code security and the requirement to report any known or suspected door code breach to the Maintenance Director and/or Administrator, with signature acknowledgment.
- Implement a camera monitoring system at the nursing station to enhance supervision of residents and monitor exit activity.
- Restrict authorization to initiate and implement door code changes when codes are compromised or breached to only the Maintenance Director and Administrator.
- In-service the Director of Nursing on operation, monitoring expectations, and response procedures related to the camera monitoring system, with signature acknowledgment.
- In-service charge nurse staff and agency staff on operation, monitoring expectations, and response procedures related to the camera monitoring system prior to start of shift, with signature acknowledgment.
- Include education on camera monitoring and reporting procedures as a required component of new hire orientation and policy change.
- Include education on door code security and reporting procedures as a required component of new hire orientation.
- Contact the door system manufacturer or security system company to request and coordinate the change of all access and exit door codes.
- Maintain sole possession of the master door code and all instructions for code changes by the Maintenance Director and Administrator.
Improper Wheelchair Securement During Van Transport Leads to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents during van transportation. A female resident with a history of left femur fracture, anxiety, and depression, and with moderate cognitive impairment (BIMS score of 10), required substantial/maximal assistance for sit-to-stand and car transfers, and walking was not attempted due to her medical condition. Her care plan identified limited physical mobility related to a fractured hip and indicated she required assistance by one staff to walk. Despite these needs, she was transported in the facility van in a wheelchair and was not properly secured using the required 5‑seatbelt restraint system. On the day of the incident, the CNA assigned to transport the resident took her to what turned out to be the wrong orthopedic office and then returned her to the van to go to the correct location. The CNA reported pushing the resident up the wheelchair ramp, locking the wheelchair wheels, and fastening the two rear seatbelts that secured the wheelchair to the floor. She then moved to the front of the van and stated she fastened the remaining three belts, which included two front straps securing the wheelchair to the floor and a lap belt over the resident’s lap. While driving, the van began to overheat in a construction zone, and as the CNA slowed down after seeing a yellow light, she heard a noise and saw that the resident’s wheelchair had flipped backwards, with the resident on the floor at the back of the van. The CNA reported that the resident’s front safety belt was unclamped and that she had to unbuckle the lap belt to move the wheelchair to reach the resident. The resident was transported by EMS to the hospital, where records documented an acute subdural hematoma and a cervical fracture following a fall from a wheelchair while being transported in a van. When interviewed in the hospital, the resident, who was wearing a cervical collar, recalled that the CNA hit the brakes and the wheelchair flipped; she stated she did not know if all straps were fastened and that she had not unfastened any safety belts herself. Facility staff later tested the van’s 5‑belt restraint system with an empty wheelchair and found that when all four floor straps and the lap belt were secured, the wheelchair could not be flipped, and even with the lap belt removed or one front strap unfastened, the chair still would not budge. The wheelchair only flipped backwards when both front straps were unfastened, leading the Administrator to state that the only way the chair could have flipped was if the two front safety belts were not fastened. Further review revealed systemic failures related to transportation safety. The Office Manager initially stated that transportation aides were trained and had demonstrated competency in wheelchair securement and safety belt placement before transporting residents, but later acknowledged there was no evidence of such training or competencies for the CNA involved or for the current transportation aide. Personnel file reviews for both aides showed no documentation of training related to transportation safety or wheelchair securement, despite a facility policy requiring that staff responsible for transportation be trained and demonstrate competency in wheelchair securement procedures, with competency documented prior to independent transport duties. Additionally, the Administrator reported that the van had no maintenance logs, no records of routine safety checks, and was not inspected routinely, even though the van had recently overheated during the incident. These inactions and lack of documented training, competency validation, and vehicle safety oversight contributed to the improper securement of the resident’s wheelchair and the resulting accident and injuries.
Removal Plan
- Ceased all resident transportation via van and wheelchair transfers requiring safety restraint usage; ceased all other facility transports unless staff were trained by nursing staff trained in safe transport and proper safety restraints.
- Required verification that safety restraints are applied correctly and staff supervision is present prior to movement; implemented and used a transport check sheet/checklist located at the nurses station; trained all transport staff on proper use of the transport checklist.
- Required that no resident is transported or transferred using the facility van until safety checks are completed and documented; completed staff in-service/sign-off for training and notification of safety checks.
- Required licensed nursing staff trained in van safety transportation to provide supervisory oversight for all transfers involving wheelchairs.
- Completed a 100% audit of all residents transported outside the facility and identified residents likely to be affected; updated care plans and implemented additional supervision for any resident identified as high risk.
- Established a standardized transportation and wheelchair restraint checklist process; implemented a Skilled Nursing Facility Transportation Safety Checklist and Wheelchair Van Restraint Safety Checklist for all nursing staff.
- Provided staff education and competency validation (return demonstration) for all staff involved in resident transfers/transportation (nurses, CNAs, drivers) on wheelchair brake locking, proper restraint use, and supervision requirements; prohibited staff from transport duties until competency is demonstrated.
- Trained all nurses on proper procedure for transports with a wheelchair upon hire and annually.
- Updated care plans to clearly identify supervision and transport requirements.
- Created/revised transportation and accident prevention policy to include training requirements, safety checklist, transportation safety, and restraint checklist.
- Adopted a zero tolerance policy for noncompliance with transportation safety procedures; made in-service mandatory for current staff and before starting first shift for new staff.
- Implemented supervisory sign-off requirement for all external transports.
- Implemented weekly preventive maintenance checks for wheelchairs and van restraints.
- Implemented monitoring/oversight: DON/designee conducts daily audits of transportation documentation, then weekly; reviews findings during QAPI meetings; initiates immediate corrective action for any noncompliance.
- Incorporated transportation safety training into new hire orientation and required annual competency validation for all applicable staff; continued ongoing QAPI monitoring to ensure sustained compliance.
- Established a standardized maintenance checklist to be reported monthly in QAPI meetings with the IDT.
Failure to Protect Resident From Abuse and to Immediately Report and Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse-prevention policies and procedures, resulting in a resident being subjected to physical abuse and staff failing to immediately report or intervene. The resident was an elderly female with vascular dementia, severe cognitive impairment (BIMS score of 4), anxiety disorder, peripheral vascular disease, osteoarthritis of both knees, and lipodermatosis. She resided on the memory care unit, was incontinent of bowel and bladder, wandered, showed inattention and disorganized thinking, and required assistance of one staff for toileting and total assistance with transfers. At the time of admission and prior to the incident, her care plan did not identify her as resisting care or being physically aggressive, and it did not specify the number of CNAs required for transfers. On the morning of the incident, multiple staff members described that the resident was sitting in a chair, yelling, and in need of incontinence care. CNA A reported to LVN D that the resident was “acting up,” was dirty, and refused to be changed. According to LVN D and CNA B, CNA A spoke loudly to the resident, attempted to get her up from the chair, and when the resident resisted and slid to the floor, CNA A grabbed the resident by the ankles and dragged her along the floor down the hallway to her room while the resident screamed, yelled, and resisted. CNA B stated that she saw CNA A pick the resident up from the chair, lower her to the floor, then drag her by the ankles from the lobby area to the resident’s room. CNA A herself stated that she pulled the resident by her legs on the floor to the room by her ankles because the resident was kicking and she was concerned about other residents nearby. Despite witnessing the event, staff did not immediately intervene to stop the abusive conduct or promptly report it as required by facility policy. LVN D stated she did not intervene because she was shocked, felt CNA A was very upset, and was concerned about aggravating the situation; she instead instructed CNA C to take over care once they reached the room and told CNA A to leave the unit. CNA B acknowledged that she did not intervene as she had been trained to do and did not notify the abuse coordinator, assuming LVN D would do so. The administrator was not informed until hours after the incident, and she delayed reporting to state and law enforcement while she sought additional information and corporate input, despite the policy requiring immediate reporting of suspected abuse to the administrator and external authorities. The facility also failed to immediately remove the alleged perpetrator from resident contact, allowing CNA A to complete her full shift on the memory care unit the day of the incident and to work another full shift the following day before suspension, contrary to the facility’s policy that any employee accused of abuse be placed on leave with no resident contact until the investigation is complete. The facility’s abuse policy required that suspicions of abuse, neglect, exploitation, or misappropriation be reported immediately to the administrator and to state and other authorities within specified time frames, and that any employee accused of abuse be removed from resident contact pending investigation. In this case, the incident occurred early in the morning, but the administrator was not notified until later that morning, and she did not immediately report the allegation to state and federal authorities or law enforcement. The former DON reported that staff approached her with concerns that the incident was not being handled appropriately and that written statements consistently described the resident being grabbed, dropped to the floor, and dragged by her feet. The DON further stated that when she raised the need to self-report, the administrator told her corporate had instructed not to self-report at that time. The incident was not reported to state authorities until months later, and the police report was filed three days after the event. These actions and inactions demonstrate that the facility did not follow its own abuse-reporting and investigation policies and did not ensure residents were protected from an alleged perpetrator immediately after an allegation of abuse.
Removal Plan
- Conduct a skin assessment for Resident #1.
- Notify the responsible party, Ombudsman, and Medical Director regarding Resident #1.
- Notify police.
- Reassign CNA A off the hallway/unit.
- Suspend CNA A pending investigation.
- Conduct skin assessments for all residents in the secured unit.
- Administer a safety survey to interviewable residents in the secured unit and conduct skin assessments for residents unable to answer.
- Provide education to designated educators/managers on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity, and complete competency testing.
- Provide education to all staff on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity, and complete competency testing prior to the next shift.
- Conduct weekly interviews of five staff and five residents for four weeks to ensure allegations of abuse are reported, and immediately address and report concerns to the administrator.
- Review progress notes and incident reports during morning clinical meetings and by the weekend supervisor to ensure any documented or potential abuse is reported to the administrator/abuse coordinator and reported to HHSC per regulation.
- Hold an ad hoc QAPI meeting with the Medical Director regarding the alleged incident and the facility’s compliance plan.
Resident dragged by CNA while staff fail to intervene to prevent abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and neglect when a CNA dragged the resident by her ankles down a hallway after the resident refused incontinent care. The resident was an elderly female on the memory care unit with vascular dementia, severe cognitive impairment (BIMS score of 4), anxiety disorder, peripheral vascular disease, osteoarthritis of both knees, and lipodermatosclerosis. Her admission MDS documented bowel and bladder incontinence, wandering, inattention, and disorganized thinking, and indicated she did not resist care or display behavioral symptoms or aggression toward others. Her care plan included mixed bladder incontinence with checks every two hours and an ADL self-performance deficit requiring assistance of one staff for toileting and total assistance with transfers, but it did not specify the number of CNAs required for transfers. The care plan was later updated after the incident to reflect resistance to care and potential physical aggression, and to include approaches such as allowing the resident to make decisions, giving clear explanations, and leaving and returning if she resisted ADLs. On the morning of the incident, CNA A was the only CNA assigned to the memory care unit on the 6:00 a.m. to 2:00 p.m. shift. According to LVN D, around 6:00 a.m. CNA A reported that the resident was “acting up,” was dirty, and refused to be changed. When LVN D went to the unit, she observed the resident sitting in a chair, smelling of feces, while CNA A stood in front of her talking loudly. LVN D stated that CNA A attempted to get the resident up, the resident refused and continued to yell, and CNA A then reached under the resident’s arms to pick her up. The resident grabbed the chair to resist and slid to the floor. LVN D reported that CNA A then grabbed the resident’s ankles and dragged her on the floor down the hall to her room while the resident screamed, yelled, and resisted. LVN D did not intervene, stating she was shocked and afraid that intervening would aggravate the situation because CNA A was very agitated and physically large. CNA B reported that shortly after 5:00 a.m. she asked CNA A for assistance, and that when CNA A entered the unit she began screaming at the resident to get up and gave her a countdown to three. CNA B stated the resident was sitting in a gray chair by the television when CNA A grabbed her, picked her up out of the chair, lowered her to the floor, then grabbed her by the ankles and dragged her from the lobby chair to her room. CNA B stated that she and CNA C only intervened once they reached the room, as directed by LVN D, and that she did not immediately intervene or report the incident herself because she believed LVN D had notified the abuse coordinator/administrator. CNA A, in her interview, claimed the resident threw herself out of the chair, kicked at her, and wrapped her arms around CNA A’s legs, and that she pulled the resident by the legs to her room out of concern for the safety of other residents nearby, while LVN D, CNA B, and CNA C did not assist. Video footage of the event, later reviewed by the administrator, police, and surveyors, showed the resident sitting in a chair in the memory care lobby with six other residents visible. LVN D stood behind the resident and did not intervene while CNA A stood over the resident, pointing and shaking her finger in the resident’s face. The video showed the resident looking up at CNA A and not resisting or striking out. CNA A then grabbed the resident under the arms, jerked her up while the resident held onto the chair arms, causing the resident to fall to the floor. CNA A immediately grabbed the resident’s right leg, then both ankles, and dragged her on her back down the hallway to her room and halfway inside the doorway before the video ended. Throughout the incident, CNA A, CNA B, CNA C, and LVN D were observed standing calmly, and no one intervened to protect the resident. The facility’s abuse, neglect, and misappropriation prevention policy stated that residents have the right to be free from abuse and neglect, including physical abuse and corporal punishment, and emphasized protecting residents from abuse by anyone and maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional problems. The surveyors determined that the facility failed to ensure residents were free from abuse and neglect, resulting in an Immediate Jeopardy situation that began on the date of the incident and was later abated.
Removal Plan
- Conduct a skin assessment for Resident #1 to confirm no open areas or bruising.
- Notify the responsible party, Ombudsman, and Medical Director.
- Notify police.
- Reassign the involved CNA away from resident care pending investigation.
- Suspend the involved CNA pending investigation.
- Conduct skin assessments for all residents in the secured unit.
- Administer a safety survey to interviewable residents in the secured unit.
- Conduct skin assessments for residents unable to answer safety survey questions.
- Provide education to designated educators (managers) on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity.
- Administer a competency test to designated educators (managers).
- Provide education to all staff on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity.
- Administer a competency test to all staff.
- Conduct weekly interviews of five staff and five residents for four weeks to ensure allegations of abuse are reported.
- Immediately address and report any concerns identified during interviews to the administrator.
- Have Department Heads or designee conduct the interviews.
- Review progress notes and incident reports during morning clinical meetings to ensure any documented abuse or potential abuse is reported to the administrator/abuse coordinator and to HHSC per regulation.
- Have the weekend supervisor review progress notes and incident reports to ensure any documented abuse or potential abuse is reported to the administrator/abuse coordinator and to HHSC per regulation.
- Hold an ad hoc QAPI meeting with the Medical Director regarding the alleged incident and the facility's plan for compliance with regulations.
Elopement of Cognitively Impaired Resident Through Malfunctioning Exit Door
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment as free from accident hazards as possible and to provide adequate supervision and assistance to prevent an elopement. The resident was an older adult male admitted with multiple serious diagnoses, including metabolic encephalopathy, protein-calorie malnutrition, hypertension, acute pulmonary edema, acute kidney failure, intestinal obstruction, enterocolitis due to C. difficile, and a cognitive communication deficit. His initial care plan identified altered neurological status, impaired cognitive function/dementia or impaired thought processes, and risk for falls, with interventions such as cueing, reorientation, monitoring for cognitive changes, and ensuring safe ambulation. At the time of the incident, the resident was on contact isolation for C. difficile and was independently ambulatory, and a Medicare 5‑day MDS documented that he scored 5/15 on a mini‑mental exam and was not capable of making informed decisions. On the night of the elopement, the resident was last seen by staff during rounds at approximately 12:20 a.m. and was later found by local police at a nearby hotel about 0.4 miles from the facility, after he had left the building without staff knowledge. It was documented that the resident had walked to the hotel, where he attempted to obtain a room because he felt he was being held “hostage” due to being kept in isolation. Nursing documentation and an elopement evaluation sheet recorded that the resident exhibited cognitive impairment, pacing, exit‑seeking, and restlessness at the time of the event. The nurse’s notes also recorded the resident’s statement that he did not want to be in the facility and believed he was being held hostage, and that he was returned to his room by police, where a skin assessment showed no new injuries. Prior to the elopement, there were indications of exit‑seeking behavior that were not acted upon in accordance with the facility’s elopement prevention expectations. An LVN reported that on the night before the elopement, the resident had tried to elope but was stopped at the door at the end of the hallway; the LVN described the resident as confused, repeatedly stating he did not want to be in the nursing home and trying to get out. The LVN later stated he did not inform anyone of this attempted elopement because the resident had not actually left the facility and he believed reporting was unnecessary. Speech therapy staff also reported that the resident was anxious, non‑compliant with the BIMS assessment, repeatedly stated he did not want to be there, and on a subsequent day was fully dressed with boots on and stated he was going home. A family member reported that the resident’s dementia was worsening, that he had recently lost his wallet and could not use his phone, and that he was very upset about being in isolation and not allowed to leave his room, all of which were consistent with the exit‑seeking and elopement behavior that ultimately occurred. The facility’s own documentation acknowledged that staff reported the 400‑hallway exit door alarm and lock did not function properly at the time of the elopement, and that the door remained unlocked despite several attempts by nurses to reset the lock. The administrator stated that three nurses could not get the 400‑hallway door to lock. Although maintenance logs showed that door locks and alarms were checked on weekdays and the maintenance supervisor stated the 400‑hallway lock had been working the day before, on the night of the incident the malfunctioning door allowed the resident to exit the building unsupervised. The combination of the resident’s known cognitive impairment and exit‑seeking behavior, the lack of reporting and escalation of a prior attempted elopement, and the failure of the 400‑hallway door locking/alarm system resulted in the resident leaving the facility unnoticed and traveling to a nearby hotel, constituting the identified accident‑prevention deficiency.
Removal Plan
- Administrator assessed all exit doors for proper function.
- Staff were posted at all exit doors until the locking/alarm system was repaired by the vendor.
- Maintenance checked all doors for proper function.
- Facility door security vendor assessed and repaired malfunctioning doors/locks (including reworking mag lock wires, reinstalling strike plate, replacing timers and a keypad, and reworking timers).
- The delayed egress/locking mechanism activation time was reduced so the locking mechanism would activate sooner.
- Signs were posted on all exit doors with instructions on how to reset the alarm once the door was open.
- Large red 'Emergency Exit Only' signs were placed on all exit doors.
- Elopement in-service training was initiated/completed for staff (Elopement Response and Prevention – Code Orange).
- Elopement drills were conducted per protocol across shifts.
- Elopement risk assessments were completed on all residents.
- Daily monitoring/rounds were implemented to check for visitors or staff allowing residents to exit unsupervised (Missing Resident/Elopement Monitoring documentation completed daily).
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