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
The facility did not ensure that residents were seen by a physician at the required intervals, with several residents missing timely in-person physician visits both during the first 90 days after admission and in the ongoing care period. Documentation showed that some residents with complex medical needs and cognitive impairments were not seen as required, and staff interviews revealed a lack of awareness of the correct regulatory schedule for physician visits.
The facility failed to ensure accurate resident assessments, with multiple instances where MDS documentation did not reflect actual skin conditions, medication use, or primary diagnoses. Several residents had discrepancies between their care plans, medication records, and MDS entries, including missing documentation of pain, antiplatelet, and antidepressant medications. Additionally, a resident was incorrectly coded regarding mental illness status and primary diagnosis on the MDS and PASARR screening, despite clear medical records. Staff interviews confirmed these inaccuracies and inconsistent review processes.
A resident with multiple diagnoses and on anticoagulant therapy did not receive all three physician-ordered guaiac stool tests, with only two documented in the medical record. Additionally, new onset bruising was not reported to the physician as required by the care plan and facility policy. The DON confirmed the missing test result and lack of reporting during the survey.
The facility did not ensure that controlled substance reconciliation logs for two medication carts were consistently signed by staff during shift changes, as required by policy. Although medication counts matched records, missing signatures on the logs indicated that the reconciliation process was not fully completed by nursing staff.
Surveyors found a loose, unlabeled pill in one medication cart and observed another cart left unlocked and unattended. Nursing staff and the DON confirmed that all medications should be properly labeled and carts should remain locked when unattended, in accordance with facility policy.
A resident with multiple health conditions and on anticoagulant and aspirin therapy had abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count. Staff did not promptly notify the physician or document the abnormal findings, and the physician was not made aware until weeks later, resulting in delayed follow-up testing and incomplete collection of ordered stool samples.
Surveyors found multiple opened and undated food items in the nourishment room fridge, including milk, soup, cheese, and meat, with the Dietary Manager unaware of their origin. The nourishment room, accessible to staff and families, is supposed to follow kitchen policies requiring opened food to be dated and properly stored, but these standards were not met.
A nurse failed to follow proper hand hygiene protocols during wound care for a resident with stage 4 pressure ulcers. After washing hands, the nurse touched the privacy curtain and door handle with bare hands before putting on gloves and continuing wound care, contrary to the facility's infection control policy. Both the nurse and DON acknowledged that this could result in contamination.
A resident with multiple serious health conditions and severe cognitive impairment had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order that was not valid due to a missing physician signature. Although the resident's representative requested DNR status and staff documented this in the electronic record, the required physician signature was not obtained, and staff acknowledged the deficiency during interviews. The facility's process for finalizing OOH-DNR orders involved multiple departments and was delayed by physician availability, resulting in the resident's end-of-life wishes not being legally documented.
A resident with severe cognitive impairment and on anticoagulant and antiplatelet therapy developed multiple bruises over several weeks, which were documented by nursing staff but not reported to the physician as required by care plan and facility policy. The DON and the resident's physician confirmed that the physician was not notified of the bruising until much later, despite clear protocols for reporting significant changes in condition.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as mandated by regulation. Specifically, four residents were not seen by a physician at least once every 30 days for the first 90 days after admission, and ten additional residents were not seen at least once every 60 days thereafter. Documentation reviewed for these residents showed significant lapses in the required physician visits, with some residents only being seen once or not at all within the required timeframes. The medical records for these residents included diagnoses such as pneumonia, diabetes, acute metabolic acidosis, dependence on renal dialysis, heart disease, fractures, osteoporosis, depression, and other chronic conditions. Many of these residents were also noted to have severe or moderate cognitive impairment and were receiving complex medication regimens, including antipsychotics, antidepressants, anticonvulsants, and hypoglycemics. Interviews with facility staff revealed a lack of awareness and understanding of the regulatory requirements for physician visit frequency. The DON confirmed that nurse practitioners were not utilized and that physician assistants assisted only once a week. The Administrator stated that the facility followed a schedule of physician visits every 30 days for new admissions and every 90 days thereafter, which does not align with the regulatory requirement of every 60 days after the first 90 days. The Medical Director also stated he was not aware of the 60-day requirement and believed visits every three months were sufficient. He relied on nursing staff to communicate any patient problems and had not discussed visit frequency with the DON or Administrator. Record review and staff interviews confirmed that the facility did not have a clear policy or consistent practice to ensure compliance with the required physician visit schedule. The documentation provided by the facility often included hospital records or telehealth/telephone visits instead of in-person physician visits, and in some cases, no recent physician visit could be found in the medical record. The lack of timely physician visits was identified for residents with significant medical and cognitive needs, and the surveyors noted that these failures could place residents at risk for medical conditions not being identified and care needs not being met.
Inaccurate Resident Assessments and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation and medication records. For several residents, the MDS assessments did not include accurate information regarding skin conditions, medication usage, and primary diagnoses. For example, one resident's significant change MDS incorrectly documented the presence of unhealed pressure ulcers, despite care plans and physician orders indicating ongoing skin care interventions. Another resident's quarterly MDS omitted documentation of pain and antiplatelet medication, even though these medications were actively prescribed and administered, as shown in the Medication Administration Records (MAR) and care plans. Additional deficiencies were observed in the documentation of antidepressant and antiplatelet medication use for other residents. In one case, a resident's MDS failed to reflect the use of both antidepressant and antiplatelet medications, despite active orders and administration records confirming their use. Similarly, another resident's MDS did not document the use of prescribed antidepressant medications, even though the care plan and MAR indicated regular administration of these drugs. These omissions were confirmed through interviews with the MDS Case Manager and Director of Nursing (DON), who acknowledged the importance of accurate MDS documentation and the expectation that staff use available medical records to complete assessments. The facility also failed to accurately code a resident's primary diagnosis and mental illness status on the MDS and PASARR Level 1 Screening. One resident was incorrectly coded with a primary diagnosis of dementia and no mental illness, despite having a documented diagnosis of bipolar disorder. Interviews with facility staff revealed a lack of clarity regarding the process for verifying and correcting PASARR assessments, as well as uncertainty about the identification of primary versus secondary diagnoses. Facility policies required review of PASARR forms for accuracy prior to admission, but documentation and interviews indicated this process was not consistently followed.
Failure to Complete Ordered Guaiac Tests and Report Bruising per Care Plan
Penalty
Summary
The facility failed to ensure that services provided or arranged, as outlined in the comprehensive care plan, met professional standards of quality for a resident with multiple medical conditions, including sepsis, cognitive decline, atherosclerotic heart disease, and dementia. The resident was on aspirin and anticoagulant therapy, with care plan interventions requiring immediate reporting of bruising and other signs of bleeding to the charge nurse and physician. Despite physician orders for three consecutive days of guaiac (fecal occult blood) testing following abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count, only two tests were completed and documented. The third required test was not found in the resident's medical records, and facility staff were unable to account for its absence. Additionally, the facility failed to report new onset bruising to the physician as directed in both the physician orders and the care plan. The facility's policy required timely notification and documentation of significant changes in resident status, including changes such as bruising, but there was no evidence that this was done. The Director of Nursing confirmed that only two guaiac test results were available and could not explain the missing third test. These failures were identified through interviews and record reviews conducted by surveyors.
Failure to Complete Controlled Substance Reconciliation Logs at Shift Change
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled for two of six medication carts reviewed. During observations of the 500/600 hall PO cart and the 100/200/600 hall PO cart, sample inventories of controlled medications showed no discrepancies between the quantities documented on individual controlled substance logs and the actual number of pills present. However, review of the comprehensive controlled medication reconciliation logs used for cart audits during shift changes revealed missing signatures: two signatures were absent on the 500/600 hall PO cart log, and one signature was missing on the 100/200/600 hall PO cart log. Interviews with nursing staff and facility leadership confirmed the expectation that the controlled substance reconciliation logs should be signed by both the staff member relinquishing and the staff member taking control of the cart at each shift change. The facility's policy requires a physical inventory of all controlled medications at each shift change, conducted by two licensed nurses or a nurse and a qualified medication aide, with documentation on an audit record. The absence of required signatures indicated that the reconciliation process was not consistently followed as outlined in facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified two deficiencies related to medication storage and labeling. On the 300/400 hall medication cart, a loose, unlabeled pill was found in the bottom of a drawer during an observation. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the presence of an unlabeled pill meant staff could not identify the medication or determine for which resident it was prescribed. The DON and Administrator both stated their expectations that all medications should be accurately labeled, properly contained, and that there should be no loose pills in the carts. Additionally, the 500/600 hall medication cart was observed to be left unlocked and unattended. Staff interviews confirmed that the cart was assigned to two nurses and that it should never be left unlocked and unattended, as unauthorized individuals, including residents who wander, could access the medications. The DON reiterated that medication carts should always be locked when unattended to prevent unauthorized access. Facility policy also requires that medications and biologicals be stored securely and that medication carts be locked or attended by authorized personnel.
Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for one resident. The resident, an elderly female with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and aspirin therapy. Her care plan required immediate reporting of symptoms or lab findings indicating complications from these medications. On 4/10/25, laboratory results showed significantly low hemoglobin, hematocrit, and red blood cell count. Despite these abnormal findings, there was no documentation in the nursing progress notes between 4/10/25 and 4/25/25 indicating that the physician was notified of these results. The physician did not review the abnormal labs or provide further orders until 5/13/25, at which point a guaiac test was ordered. The facility subsequently collected only two of the three required stool samples for this test, and both were negative for occult blood. The Director of Nursing confirmed that staff should have immediately notified the physician of the abnormal labs and documented this action, but was unable to explain the delay in physician review or the incomplete collection of ordered tests. Facility policy required prompt physician notification and documentation for abnormal lab results, which was not followed in this instance.
Undated Opened Food Items Found in Nourishment Room Fridge
Penalty
Summary
Surveyors observed that the nourishment room fridge contained multiple opened food items that were not dated, including a bottle of chocolate milk, containers with soup-like substances, a to-go box, an item wrapped in foil, cheese slices in plastic wrap, and a container of meat. These items appeared to have been previously opened and were not labeled with dates, contrary to facility policy. The Dietary Manager confirmed responsibility only for snacks placed in the fridge by dietary staff, which are labeled and dated daily, but was unaware of the origin or status of the other items found during the inspection. Further interviews revealed that the nourishment room is accessible to all staff and families, with no code required for entry, and is intended for resident use only. The Administrator stated that the nourishment room is subject to the same policies as the kitchen, which require opened food packages to be stored in closed containers or sealed bags and dated when opened. The presence of undated, opened food items in the fridge indicated a failure to follow these professional standards for food storage and safety.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
A deficiency occurred when a nurse failed to maintain proper hand hygiene during wound care for a male resident with two stage 4 pressure ulcers. The resident, who had severe cognitive impairment and a history of pressure injuries, required daily wound care as per physician orders. During an observed wound care procedure, the nurse washed her hands in the resident's bathroom but then touched the privacy curtain and door handle with her bare hands before donning gloves and continuing wound care. This sequence of actions was observed twice during the same procedure, once for each wound. The facility's infection control policy required hand hygiene before and after resident care, after contact with potentially contaminated surfaces, and after removing gloves. The nurse did not use hand sanitizer or rewash her hands after touching potentially contaminated surfaces before resuming wound care. Both the nurse and the Director of Nursing acknowledged during interviews that this practice could result in the transfer of germs to the resident, which is inconsistent with the facility's infection control protocols.
Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) order was valid, as the required physician's signature was missing from the form. The resident in question was an elderly male with multiple significant medical conditions, including acute kidney failure, dependence on renal dialysis, hypertension, hyperlipidemia, and heart failure. He was severely cognitively impaired and required regular dialysis treatments. Documentation showed that the resident's representative had requested DNR status, and the facility's records, including the electronic profile and care plan, reflected a DNR order. However, the OOH-DNR form lacked the physician's signature, rendering it invalid according to state requirements. Interviews with facility staff revealed a lack of clarity and consistency in the process for obtaining and finalizing OOH-DNR orders. Nursing staff, the ADON, and the SW all confirmed that the resident was listed as DNR in the electronic record, but upon review, the OOH-DNR form was found to be incomplete due to the missing physician signature. The SW, who was responsible for auditing OOH-DNR forms, acknowledged the deficiency and stated that the facility was still waiting for the physician to sign the document. The DON and other staff described a process in which the OOH-DNR form was initiated at admission, signed by the resident or representative, and then routed through various departments before being presented to the physician for signature. Delays in obtaining the physician's signature were attributed to the physician's availability and the process of delivering the form to the physician's office. Despite the lack of a valid OOH-DNR form, staff indicated that they would honor the family's wishes based on the signed request for DNR status, even though the form was not legally valid without the physician's signature. The Medical Director stated that the OOH-DNR should be signed within 24 hours of the order being entered into the electronic record, and that without the physician's signature, the resident would be considered full code. Facility policy and state guidance both require a properly executed OOH-DNR form, including all necessary signatures, for the order to be valid and honored by health professionals.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically the development of multiple bruises over several weeks. The resident, an elderly female with diagnoses including sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and antiplatelet therapy, which increased her risk for bleeding and bruising. Despite care plan and physician orders requiring staff to monitor for and report signs of bruising or bleeding, documentation showed that a nurse recorded the presence of multiple bruises on the resident's arms and legs on three separate weekly skin assessments but did not notify the physician as required. Observations and interviews confirmed that the resident had extensive bruising on both arms, which had been present for about 15 days. The resident was unable to recall the cause of the bruises and was noted to have severe memory impairment. Staff interviews indicated that the resident was known to bruise easily, and protective measures such as geri sleeves were used. However, the nurse responsible for the resident's care acknowledged that she had not communicated the bruising to the physician, despite being aware of the ongoing issue and the care plan's instructions. The Director of Nursing (DON) confirmed that the nurse should have completed an incident report and notified both the DON and the physician about the bruising. The resident's primary physician stated he was not made aware of the recent bruising until notified by the DON, and he indicated that he would have provided different medical orders had he been informed earlier. Facility policy required timely physician notification and documentation of significant changes in resident status, which was not followed in this case.
Some of the Latest Corrective Actions taken by Facilities in Texas
Staff Education & Competency
- Delivered targeted trainings for therapy and nursing staff on correct donning/doffing of assistive devices, obtaining physician orders before placement, time restrictions, and skin-integrity monitoring (K - F0684 - TX)
- In-serviced all licensed nurses on comprehensive skin and pressure-ulcer assessments, documentation, and timely provider notification, with post-tests requiring ≥90% competency before staff may work (K - F0686 - TX)
- Provided 1:1 education to Treatment Nurse on pressure-ulcer identification and obtaining appropriate treatment orders (K - F0686 - TX)
- Re-educated nursing staff on weekly skin-assessment procedures, accurate EMR documentation, and protocols for residents who are unavailable for consultation (K - F0686 - TX)
- Trained nurses on admission-wound protocols, including immediate physician notification, treatment initiation, and distinction between notifying attending physicians versus wound-care specialists (K - F0686 - TX) (K - F0580 - TX)
- Re-educated nurses on reporting any change in skin condition and documenting all physician interactions (K - F0580 - TX)
Ongoing Monitoring & Policy Enhancements
- Implemented continuous monitoring of hand-roll/splint placement, removal, and associated skin integrity, with corresponding orders and care-plan entries in the treatment record (K - F0684 - TX)
- Established weekly head-to-toe skin assessments for all residents and mandatory assessments upon every admission/readmission, verified by DON/Designee (K - F0686 - TX) (K - F0686 - TX)
- Initiated daily and weekend IDT oversight of new admissions and required daily wound reports from the Treatment Nurse during clinical stand-up meetings (K - F0686 - TX)
- Instituted weekly narrative wound assessments for each pressure injury and weekly audits of new admissions to ensure prevention measures and orders are in place (K - F0686 - TX)
- Began daily review of missing treatment-documentation and 24-hour reports to confirm wound-care documentation and physician communication completeness (K - F0686 - TX) (K - F0580 - TX)
- Assigned a dedicated nurse to compile a weekly skin report, with scheduled Tuesday administrative review meetings to evaluate interventions and treatment effectiveness (K - F0686 - TX)
- Contracted a wound-care company to provide on-site weekly resident evaluations, staff training, and progress reports, replacing the prior consulting physician (K - F0686 - TX) (K - F0580 - TX)
- Established facility-wide daily stand-down meetings led by Administration and DON to verify completion of wound-care tasks, documentation, and orders (K - F0686 - TX) (K - F0580 - TX)
- Implemented DON and Weekend Supervisor monitoring of skin-assessment completion and divided daily wound-care tasks between shifts to ensure adequate assessment time (K - F0686 - TX)
Failure to Monitor and Document Palm Protector Use Leads to Severe Hand Injury
Penalty
Summary
A resident with severe cognitive impairment, hemiplegia, and multiple comorbidities was admitted to the facility and was dependent on staff for all activities of daily living. The resident had a history of contractures and was at risk for skin breakdown, as documented in his care plan. Despite these risks, a palm protector device was placed on his contracted left hand without a physician's order, care plan update, or proper monitoring. The device remained on the resident's hand for approximately seven days, during which time staff failed to remove the device to assess the underlying skin integrity, as required by professional standards and facility policy. Multiple staff members, including nurses and CNAs, observed the device on the resident's hand but did not remove it or adequately assess the skin beneath. Some staff were unaware of who placed the device or the need for monitoring, and there was no documentation of the device in the resident's treatment record. The therapy department did not recommend the device, and the occupational therapist could not find any documentation supporting its use for this resident. Nursing staff performed routine skin assessments but did not remove the device, and changes in the resident's hand condition, such as swelling, redness, and the presence of a wound, were either not noticed or not reported in a timely manner. The deficiency became evident when the resident was observed with a swollen, red, and painful left hand, with a deep, foul-smelling wound in the thenar web space. The device was found embedded in the wound, and the resident was subsequently transferred to an acute care hospital, where he was diagnosed with cellulitis, leukocytosis, and a deep, chronic-appearing pressure wound. Interviews with staff revealed a lack of training and awareness regarding the use and monitoring of assistive devices, as well as failures in communication and documentation. The facility's failure to ensure proper assessment, monitoring, and documentation of the palm protector device directly led to the resident developing a serious, avoidable injury.
Removal Plan
- Audit all residents with palm protectors and splints to ensure orders and care plans are in place
- Educate staff
- Conduct skin sweep
- Monitor hand roll/splint placement, removal, and skin integrity
- Train therapy department on donning and doffing of braces, splints, and palm guards
- Train nursing and therapy staff on assistive devices, including obtaining doctor's orders prior to placement, notifying nursing department of order and device placement, and monitoring as indicated
- Train nursing staff, including CNAs, nurses, and medication aides, on notification of changes of condition, including any change to a resident's skin, and reporting the change of condition to the nurse
- Educate Treatment Nurse A on skin assessments and removing assistive devices to assess skin integrity
- Implement orders, care plans, and monitoring on treatment record for residents utilizing palm protectors and splints
- Assess all residents' skin for suspicious areas or marks
- Complete skin assessments for all residents
- Train therapy and nursing staff on assistive device procedures, including obtaining an order, following the order including time restrictions for the device, and monitoring the use of the device
Failure to Identify and Treat Pressure Ulcer Resulting in Amputation
Penalty
Summary
A seventy-six-year-old woman with multiple comorbidities, including Type 2 diabetes, metastatic cancer, and recent hip replacement, was admitted to the facility. Upon admission, her hospital records documented a pressure injury to the right heel, but the facility's admission assessment did not identify any wounds, and she was marked as bed bound. Weekly skin assessments were inconsistently documented, with some entries indicating existing skin alterations and others not specifying the location or using unclear abbreviations. The resident was dependent for mobility and at high risk for pressure ulcers, but the care plan interventions, such as floating heels and a pressure redistribution mattress, were not consistently implemented or documented. The resident began to complain of foot pain, which she reported to nurses, the NP, and PT staff over several weeks. Despite these complaints, the wound on her right heel was not promptly or accurately identified. When a blister on her heel burst during physical therapy, it was initially treated as a simple blister rather than a pressure ulcer. The wound care nurse (WCN) did not consult the wound care nurse practitioner (WCNP) immediately, and there was confusion and lack of documentation regarding the wound's assessment and treatment. The wound progressed to a necrotic state with signs of infection, including odor and increased size, but wound care was not provided daily as ordered, and documentation of care was inconsistent. The resident and her family reported that wound care was infrequent, and the mattress provided was uncomfortable and not replaced despite complaints. The wound continued to deteriorate, and the resident was eventually admitted to the hospital with a necrotic pressure ulcer requiring possible amputation. Hospital staff found the wound to be unstageable due to extensive slough and necrosis. Interviews with facility staff revealed lapses in communication, assessment, and documentation, including failure to complete required SBAR assessments and progress notes. The WCN and ADON acknowledged gaps in their documentation and assessment processes, and the WCNP confirmed that the wound was not seen promptly after it opened. Ultimately, the resident underwent an above-the-knee amputation due to the infected pressure ulcer.
Removal Plan
- Skin sweep of all residents to assess for any worsening or unidentified pressure ulcers to identify and provide treatment to all pressure ulcers. The skin sweep was completed by RDCS, DON, DON #2, UNIT MANAGER, and Treatment Nurse with no new findings or negative outcomes.
- Conduct Emergency QAPI meeting regarding pressure ulcers including notification to the medical director.
- RDCS/DON/Designee audit new admissions and readmissions to ensure any pressure injuries are identified appropriately, prevention measures in place, and treatment orders, as applicable.
- Complete in-services regarding pressure ulcers for all licensed nursing staff including head to toe skin assessments, newly identified wounds will be assessed and documented with notifications to RP and medical provider, skin assessment will be completed by charge nurse or treatment nurse for any new admission or readmission, and treatment orders will be obtained as applicable.
- Implement quick interventions to prevent further breakdown of identified pressure ulcers by providing air mattresses for residents as applicable.
- Each Licensed Nurse will complete a post-test after their education is completed to ensure staff comprehend in-services. If the employee does not pass the test with at least 90% correctly answered the staff member will be re-educated and re-tested until at least 90% pass rate is met.
- DON/Designee will utilize a staff roster to ensure 100% compliance with education. Licensed nurses will not be allowed to work until in-services are completed by DON/Designee.
- Head to toe skin assessments of all residents will be completed by the Director of Nursing (DON), Treatment Nurse, Assistant Director of Nursing (ADON), and Regional Compliance Nurse.
- All newly admitted residents will have a head-to-toe skin assessment completed by the licensed nurse or treatment nurse and verified by the DON/Designee to ensure all pressure ulcers are identified upon admission and readmission and ensure appropriate treatment.
- Nursing staff will be in-serviced by the RDCS, DON, ADON, UM and Treatment Nurse on these protocols.
- Clinical staff will not be allowed to work their scheduled shift until they have completed all education related to the IJ.
- The Treatment Nurse or Nurse Manager designee will complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment.
- Head-to-toe assessments must be completed weekly.
- Any newly identified wounds will be addressed by the Treatment Nurse or Licensed Nurses to include assessment and documentation of the skin site and initiate appropriate clinical interventions.
- Notify the Patient's Representative and Medical Provider of any new or change in the existing wound(s) and document in EMR.
- A Wound Assessment will be completed by the Treatment Nurse or Licensed Charge Nurse and a narrative of each site will be documented weekly for any pressure injury.
- RDCS/DON will complete an audit of all findings to ensure implementation of skin system.
- Notify the Medical Director of the Immediate Jeopardy by Executive Director.
- Conduct emergency QAPI meeting.
- The Treatment Nurse will receive 1:1 education and counseling regarding identification of pressure ulcers including worsening of wounds and obtaining orders from the physician for appropriate treatments.
- The treatment nurse will present a clinical wound report every day during the Clinical Stand-Up Meeting.
- DON/Designee will monitor new admissions during daily clinical IDT Stand Up meeting to ensure skin assessments have been completed upon admission and interventions and treatment orders are in place, as applicable.
- RN Weekend Supervisor will monitor new admissions on the weekend to ensure skin assessments have been completed upon admission and interventions and treatment orders are in place, as applicable.
- Facility policies & procedures will be reviewed by the DON, RDCS, VP of Operations, VP of Clinical Services and Director of Education. The policies and procedures will be included in the staff in-servicing.
Delayed Response to Acute Fracture and Change in Condition
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, non-Alzheimer's dementia, and a history of stroke did not receive timely and appropriate care following a significant change in condition. The resident, who was bedbound and dependent on staff for all activities of daily living, began experiencing severe pain and swelling in the left knee. Despite multiple complaints of pain from the resident and reports from family members, nursing staff failed to conduct thorough assessments, document findings, or notify the physician or nurse practitioner promptly. Pain assessments were inconsistently performed, and there was a lack of documentation regarding the resident's pain and condition changes during several shifts. When the resident's pain escalated and was unrelieved by PRN pain medications, staff delayed in escalating care and obtaining necessary diagnostic imaging. An x-ray was eventually ordered and performed, revealing a displaced distal femoral shaft spiral fracture. However, after the facility received the x-ray results indicating an acute fracture, there was a delay of approximately 13 hours before the resident was transported to the hospital for emergency evaluation and surgery. During this period, staff did not immediately notify the physician or nurse practitioner, nor did they reassess or adequately monitor the resident's condition. Interviews with staff and family confirmed that the resident's pain was not effectively managed, and communication breakdowns occurred at multiple points, including failure to document assessments, notify appropriate clinical leadership, and act on critical diagnostic findings. The facility's own Director of Nursing acknowledged that the change in condition should have been recognized and acted upon much earlier, and that the delay in care could have resulted in continued pain and adverse outcomes for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) will be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.
- Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- The Administrator will ensure the plan is completed in full.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- All In-service sign-in sheets were requested and reviewed.
- Interviews were conducted on all shifts with staff to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them.
Failure to Immediately Notify Physician and Act on Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify appropriate parties when there was a significant change in the resident's condition. The resident, who had severe cognitive impairment, non-Alzheimer's dementia, a history of stroke, and was dependent on staff for all activities of daily living, began experiencing pain and swelling in the left knee. Despite complaints of pain and visible swelling, nursing staff did not promptly assess, document, or notify the physician or nurse practitioner of the change in condition. Pain assessments and administration of PRN pain medications were delayed, and there was a lack of timely documentation and follow-up regarding the resident's ongoing pain and swelling. On multiple occasions, the resident reported severe pain (rated 8 out of 10) and swelling in the knee, but staff failed to immediately notify the physician or seek medical guidance. The resident's family member also reported the pain and swelling to staff, but the response was inadequate, with staff either not documenting the incident or not escalating the issue appropriately. When an x-ray was eventually ordered and revealed a displaced distal femoral shaft spiral fracture, there was a significant delay—approximately 13 hours—before the resident was transported to the hospital for emergency surgery. During this period, the resident continued to experience severe pain without appropriate intervention or escalation. Interviews with staff and review of records confirmed that there were lapses in assessment, documentation, and communication regarding the resident's change in condition. Staff failed to recognize the significance of the resident's symptoms, did not follow the facility's policy for notification of changes, and did not act promptly on critical diagnostic information. The delay in seeking medical attention and transporting the resident to the hospital after the fracture was identified resulted in prolonged pain and delayed treatment for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) are to be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers.
- Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- Charge Nurses, CNA's and Med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- Monitoring began including review of all in-service sign-in sheets and staff interviews to validate understanding and compliance.
Significant Medication Errors Due to Omission and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of critical medications for two residents. For one resident, Metoprolol and Entresto, both prescribed for hypertension and heart failure, were not administered as ordered on a specific evening. Additionally, upon admission from the hospital, Entresto was not ordered for another resident, despite it being listed on the hospital discharge medication list. This omission was not identified or corrected by the admitting nurse or subsequent staff responsible for medication reconciliation and order entry. The same resident also failed to receive Eliquis, an anticoagulant prescribed for atrial flutter, on eight occasions in a single month. The medication administration record (MAR) showed multiple blanks with no documentation to indicate whether the medication was given or refused. Interviews with nursing staff revealed inconsistent documentation practices, with some staff admitting to forgetting to chart medication administration or not following up on missed doses. There was also a lack of clarity and communication regarding the process for documenting refusals and ensuring that all medications were administered as ordered. The resident who missed multiple doses of Eliquis was later hospitalized and diagnosed with atrial fibrillation with rapid ventricular response, acute on chronic systolic and diastolic heart failure, and a small pulmonary embolus. Staff interviews indicated that the resident was sometimes noncompliant or refused medications, but there was no consistent documentation of refusals or evidence that appropriate notifications were made to the physician or family. The facility's policies required that all medication refusals or omissions be documented in the MAR, but this was not consistently followed, leading to significant medication errors.
Removal Plan
- The administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will complete medication order reviews for all residents admitted and re-admitted to ensure no residents are in jeopardy or threat of harm.
- Chart reviews of the remaining residents admitted and re-admitted will be completed by the administrative nursing team with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations to ensure accurate reconciliation of hospital discharge orders/admitting orders to those that were verified with the attending physician and transcribed into the electronic health record.
- Chart reviews will ensure all diagnosis/health conditions of residents is being/has been addressed/noted in the electronic health record.
- The Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were counseled and provided with an in-service by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing medication report each morning during the morning meeting process.
- The Facility Administrator will be responsible for ensuring the daily review of the missed medication report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible.
- All nurses and certified medication aides present at the time of the notification will be provided with in-service training regarding the admission/re-admission process, the admission/readmission medication reconciliation process, transcribing and carrying out physician orders, how to document different scenarios of medications not given (refused, spit out, held for vital signs outside of parameters, etc.), checking the dashboard throughout and at the end of their shift to ensure no medication documentation is missing.
- The staff in-service will be conducted by the Administrative Nursing Team and will continue until all nurses and certified medication aides have been provided with the beforementioned education; the remaining nurses and certified medication aides will be educated prior to beginning their next shift.
- All newly hired nurses and certified medication aides will be educated regarding how to document missed doses, refused doses, and accessing the dashboard to ensure all doses are accounted for before the end of their shift before beginning their first assigned shift.
- A QAPI meeting was conducted with the Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations, and Assistant Corporate Director of Clinical Operations. The root cause analysis of the alleged deficient practice was reviewed and interventions to correct and prevent future occurrence were discussed.
- The Consultant Pharmacist was contacted by the Corporate Director of Clinical Operations and discussed the alleged deficient practice; it was decided that all new and re-admissions to the facility will be reviewed by a pharmacist with the consultant pharmacy group every Monday, Wednesday and Friday.
- The Consultant Pharmacist will review all residents admitted /re-admitted to the facility. In addition to the regular medication regimen review the consulting pharmacist will reconcile current physician orders to those given from the discharging entity. Upon completion of his/her review, the consulting pharmacist will provide a summary of findings/recommendations to the Director of Nursing, Assistant Director of Nursing and Facility Administrator. Immediately upon receipt of the recommendations the Director of Nursing will ensure any physician recommendations are addressed and carried out.
- The recommendations from the consultant pharmacist will be reviewed during the morning meeting Monday through Friday and the Facility Administrator and Director of Nursing will verify they are complete with a physician acceptance or declination, orders corrected or changed as recommended/agreed to by physician, plan of care updated, and resident/resident representative informed of changes.
- The Corporate Director of Clinical Operations will provide an in-service to the Facility Administrator and administrative nursing staff regarding the review of the pharmacy consultant admission/re-admission drug regimen review/medication reconciliation process that is to be reviewed during the morning meeting every Monday through Friday.
- The facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will begin a full audit of all resident medication orders.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure injuries for four residents. For one resident, weekly skin assessments were not completed after a certain date, and there was a delay in obtaining and implementing wound care orders after an unstageable pressure injury was identified. Additionally, dietary recommendations from the dietician were not implemented, and wound care treatments were missed on multiple days, with no documentation of resident refusal. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but wound care orders were not obtained or implemented until several days after admission, and head-to-toe skin assessments were not completed as required. Wound care was also missed on several days for this resident. A third resident experienced deterioration of an existing pressure wound, which progressed from stage 3 to stage 4 and increased in size. Wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a certain date. An intervention for a low air loss mattress, as specified in the care plan, was not implemented. For a fourth resident, wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a specific date. There was no documentation that this resident refused treatment for her wound. Observations and interviews revealed that staff were not consistently performing or documenting required skin assessments and wound care. The facility did not have a designated treatment nurse, and floor nurses were responsible for wound care and assessments, but these tasks were often not completed as scheduled. Staff interviews indicated a lack of accountability and follow-through, with missed documentation and communication lapses regarding wound care orders and changes in resident condition. Facility policies required notification of the attending physician for new skin alterations and evaluation and documentation of skin changes, but these procedures were not consistently followed.
Removal Plan
- Dietary recommendations for Resident #11 were approved with orders written.
- Consulting wound care physician was contacted by the Corporate Director of Clinical Operations regarding Resident #11's wound and treatment orders.
- Resident representative for Resident #11 was contacted to determine preferred wound care physician.
- Resident #11 scheduled to be seen by the wound care physician.
- Wound care consulting physician was contacted by the Corporate Director of Clinical Operations regarding Resident #12 to inform of most recent measurements and wound condition.
- Resident representative for Resident #12 was notified of current wound condition by the MDS Coordinator.
- Admitting nurse for Resident #12 was provided with individual education regarding ensuring residents admitted with a wound have orders for treatment, notifying the physician, and immediately rendering treatment upon admission.
- Wound care consulting physician was notified by the MDS coordinator regarding Resident #13's wound condition.
- Resident representative for Resident #13 was notified by the MDS Coordinator.
- All nursing staff present at the time of notation were provided with an in-service on how to document when a resident is not available for a visit by a consulting provider.
- Facility MDS coordinator evaluated all current wounds, measured wounds, and documented the condition of all wounds in the Skin Issue evaluation of the electronic health record.
- Nursing administration team compared all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- All nurses present at the time of notification were re-educated in the form of an in-service regarding completion of weekly skin assessments, including how to complete the assessment, what to look for, when to complete the assessment, what to document, and when to report skin issues.
- Nurses will be provided with notification of consequences for failure to complete scheduled skin assessments during their shift.
- Completion of skin assessments will be monitored by the Director of Nursing and by the designated Weekend Nursing Supervisor.
- A complete head to toe skin inspection was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Assistant Corporate Director of Clinical Operations on all residents.
- Nurses present at the time of notification were in-serviced by the administrative nursing team regarding admitting a resident with wounds, informing the physician, obtaining orders for treatment, ensuring orders for treatment are initiated immediately, and inquiring about existing wounds when receiving report from the discharging facility.
- Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Facility Administrator were re-educated on reviewing the missing documentation report for the Treatment Administration Record from the electronic health record.
- The missing documentation report for Treatment Administration Records will be reviewed by the Director of Nursing during the morning clinical meeting.
- Facility Administrator will ensure review of missed documentation report, admission record review, admission order reconciliation, and review of the 24/72-hour report.
- Facility has begun the process of replacing the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management.
- Another provider has been contacted and is willing to provide wound care consultant nurse practitioner service.
- Facility Administrator and Administrative Nursing Team will review the nursing schedule to ensure one designated nurse is scheduled to review wounds, complete measurements, evaluate wound condition and prepare the weekly skin report at least once per week.
- Weekly skin report will be reviewed by the Administrative Nursing Team and the Facility Administrator to ensure all interventions are present including supplements/vitamins as recommended by the registered dietician, support surfaces are appropriate, and treatments are evaluated for effectiveness.
- Weekly skin report review meeting will occur on Tuesday of each week.
- The Assistant Director of Nursing will divide daily treatments/wound care between the day shift and night shift to allow floor nurses more time to complete the treatment/skin assessment processes.
- A daily stand-down meeting will be held by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
Failure to Notify Physicians and Obtain Timely Wound Care Orders Following Changes in Resident Condition
Penalty
Summary
The facility failed to promptly notify physicians and obtain appropriate wound care orders when residents experienced changes in condition, specifically related to pressure injuries. For three residents reviewed, there were significant lapses in communication and documentation. One resident developed an unstageable pressure injury to the right heel, but the wound care physician was not notified until two days after the injury was identified, and there was no documentation of physician notification or wound care orders on the day the wound was discovered. Additionally, after a surgical debridement, the facility did not contact the surgeon or wound care physician to obtain updated wound care orders. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but the facility did not obtain or implement wound care orders until several days after admission. Documentation showed that while the resident's physician was notified of the admission, there was no evidence that the wounds were reported or that wound care orders were requested at that time. For a third resident, the facility failed to monitor and report the status of a stage 4 pressure ulcer to the wound care physician, and there were gaps in the completion of required skin assessments. Interviews with staff revealed ongoing issues with accountability and follow-through regarding skin assessments and wound care. The facility did not have a dedicated treatment nurse, and regular nursing staff were responsible for these tasks, leading to inconsistent completion of assessments and treatments. Staff also reported confusion about when and how to notify physicians and document changes, and there was a lack of clear processes for ensuring timely physician notification and order implementation when residents' conditions changed.
Removal Plan
- Contact the facility wound care consulting provider to ensure no information had been relayed regarding the residents currently under care.
- Discuss Residents #11, #12, and #13 with the MDS Coordinator and the Assistant Director of Clinical Operations; ensure no new orders are needed.
- Contact the consulting wound care physician and inform of the resident being seen by the surgeon, debridement, and wound deterioration.
- Contact the resident representative and inform of the debridement, deterioration of the wound, and ask which consulting wound physician is preferred.
- Contact the wound care consulting physician to inform of the most recent measurements and wound condition for Resident #12.
- Compare wound measurements and condition for Resident #13 to previous observations and notify the wound care consulting physician.
- Notify the resident representative for Resident #13.
- Compare all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- Re-educate all nurses present regarding when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care, and how to contact the wound care consulting physician.
- Continue in-service until all nurses have been in-serviced and provide re-education prior to beginning their next scheduled shift.
- Review the 24-hour report to ensure a progress note is written when the wound care physician visits each resident and when the wound care physician is contacted to update with changes in wound condition.
- Provide education to all nurses regarding the completion of the Skin Issues evaluation when a new wound is discovered or when a resident is admitted with a wound, to notify the Director of Nurses and Facility Administrator, to notify the attending physician and/or the consulting wound care physician to obtain treatment orders and begin treatment orders immediately upon receipt, to make a notation on the 24-hour report of the new wound and to inform the Certified Nurse Aides of the residents wound and any changes needed for the residents plan of care.
- In-service nurses regarding admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility.
- Re-educate nurses regarding notification of the physician when there is a change in condition of a wound and remind to document all physician interaction in the electronic health record.
- Replace the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management to ensure treatment and services are provided to prevent and heal pressure ulcers.
- Hold a daily stand-down meeting by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
- Conduct an impromptu QAPI meeting with the Facility Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations and Assistant Director of Clinical Operations.
- Ensure all residents have a current skin assessment completed and documented in the electronic health record and all residents with wounds are evaluated to ensure all appropriate interventions are in place and the attending physician and consulting wound care physician have been notified.
Failure to Administer Prescribed IV Antibiotic Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including sepsis due to E. coli, severe wounds, and dependence on renal dialysis, was admitted to the facility. Upon admission, the resident had physician orders for IV antibiotic therapy (Piperacillin-Tazobactam/Zosyn) to treat infections related to wounds, urinary tract, and pneumonia. Despite these orders, the resident did not receive the prescribed IV antibiotic from the time of admission for several days. Record reviews showed that the medication was not administered as ordered, and there was no documentation of administration for multiple scheduled doses. Additionally, there was confusion regarding IV access, with delays in arranging for a midline catheter and issues with the pharmacy dispensing the correct antibiotic dosage. Interviews with facility staff revealed that the admitting nurse did not ensure all admission orders were entered before the end of her shift, and there was a lack of timely communication with the medical provider regarding the inability to administer the antibiotic. The medical director and nurse practitioners were not notified of the missed doses or the issues with medication availability and IV access. The wound care physician was also unaware that the resident had not received the ordered antibiotic therapy. Progress notes indicated that the resident had no IV access for the antibiotic, and there was a delay in obtaining the correct medication from the pharmacy. The facility's policy required medications to be administered as prescribed and for staff to notify providers of any issues, but these procedures were not followed. The resident's condition was further complicated by extensive wounds, including stage four pressure ulcers and necrotic tissue, and she was nonverbal and dependent on staff for all care. Observations documented the severity of her wounds and her lack of response to painful procedures, likely due to her cognitive and physical impairments. The failure to administer the prescribed IV antibiotic as ordered was identified as a significant medication error, and the facility was cited for not ensuring residents were free from such errors.
Removal Plan
- SBAR/Change of condition assessment completed with notification of provider and responsible party regarding the missed IV antibiotics.
- Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered.
- 100% audit completed of facility residents to identify any residents with IV antibiotics. No additional residents identified as receiving IV antibiotics.
- 100% audit completed of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on facility residents identified as missing medications/treatments.
- Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding: admission Process to include reconciling treatment and medication orders.
- Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding the admission Process to include reconciling treatment orders and medication orders. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding Medication Administration. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor admission Process daily to ensure any new admissions and readmissions had reconciled treatment and medication orders.
- Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into the facility's electronic record.
- DON/Designee will monitor Medication & Treatment Administration Records daily to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting.
Failure to Provide and Document Hemodialysis Services as Ordered
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, dependent on hemodialysis, did not receive her prescribed dialysis treatment for a period of four days. The resident, who was severely cognitively impaired and fully dependent on staff for activities of daily living, was admitted with multiple complex medical conditions, including a central line for dialysis access. On the scheduled dialysis day, the resident was unable to receive treatment due to an elevated heart rate, and although the nephrologist and facility nurse attempted interventions, the dialysis session was not completed. Following the missed dialysis session, there was a breakdown in communication and documentation among facility staff. The charge nurse did not clearly document the missed dialysis or the resident's change in condition in the 24-hour report or other required communication tools. The nurse also failed to ensure that the physician or nurse practitioner was adequately notified regarding the missed dialysis and did not follow up on orders for medication administration or alternative interventions. Other staff members, including the DON and ADON, were unaware of the missed treatment until after the fact, and there was no evidence that the resident's care plan or medical record was updated to reflect the missed dialysis or any follow-up actions. The facility's policies required prompt notification of a physician in the event of a change in status or missed treatment, as well as thorough documentation of all communication and interventions. These procedures were not followed, resulting in the resident missing dialysis for four consecutive days. The failure to provide dialysis as ordered and to communicate and document the missed treatment placed the resident at risk for delayed treatment and actual harm, as identified by surveyors.
Removal Plan
- Review all facility residents receiving dialysis to identify any other residents receiving dialysis treatments.
- Assess all facility residents ordered to receive hemodialysis treatments to ensure no other residents missed hemodialysis treatments.
- Regional Compliance Nurse provides in-service to DON, ADON, and Administrator regarding Change of Condition (when to Report to MD/NP/PA and follow-up communication), Abuse/Neglect, and Dialysis (facility's dialysis policy in-serviced for enforcement).
- DON/ADON will in-service facility staff by phone and/or in person regarding facility policy on Abuse/Neglect. Facility staff, including PRN staff, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding Change of Condition to include when to Report to MD/NP/PA. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- DON/ADON will in-service nurses (LVN/RN) by phone and/or in person regarding facility's dialysis policy. All nurses (LVN/RNs), including PRN nurses, not in serviced will not be allowed to provide resident care until training has been completed.
- Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR).
- Notify the Medical Director regarding the immediate jeopardy citation.
- Hold an Ad-hoc QAPI meeting by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will monitor changes of condition to ensure changes of condition have been reported to the MD and followed up.
- DON/Designee will monitor Dialysis residents to ensure that residents did not miss any dialysis or had any incomplete dialysis session, if dialysis sessions were missed or incomplete that an SBAR was completed, and was the resident monitored.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with multiple severe wounds, resulting in a deficiency identified by surveyors. The resident, a female with a history of cerebral infarction, sepsis, end-stage renal disease requiring dialysis, and multiple stage four pressure ulcers and arterial wounds, was admitted with significant medical complexity and was nonverbal with severe cognitive impairment. Despite her extensive wounds and high risk for pain, there was no care plan for pain, and her pain was not assessed or managed according to professional standards or her needs. Observations revealed that during wound care procedures, the resident exhibited clear signs of pain, such as wincing, deep breathing, and tears, particularly when bandages were removed and wounds were treated. Staff failed to assess her pain prior to wound care, did not provide timely or appropriate pain medication, and did not stop procedures to reassess or address her pain when she showed distress. Documentation showed that although there were orders for acetaminophen, these were not administered, and staff were unclear about pain assessment tools and procedures. Interviews with nursing staff indicated confusion about responsibilities for pain management, lack of documentation, and a failure to communicate or follow up on the resident's pain needs. The attending physician and wound care doctor were not notified of the resident's pain, and no additional pain management interventions were implemented until after the surveyor's intervention. The facility's own policy required assessment and management of pain, including for nonverbal residents using the PAINAD tool, but this was not followed. The deficiency was identified as Immediate Jeopardy due to the failure to provide pain management consistent with professional standards, the resident's care plan, and her goals and preferences, resulting in unmanaged pain during daily wound care treatments.
Removal Plan
- The treatment where the resident was experiencing pain was stopped until adequate pain relief could be achieved.
- Primary care provider was contacted by the director of nurses and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose prior to wound care.
- 100% review of residents receiving wound care for PRN pain medication orders that may be given prior to wound care was completed by Regional Compliance nurse/DON/Designee.
- Residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed.
- Resident identified in the audit has an allergy to acetaminophen.
- Care plans for facility residents with wounds were updated by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective.
- Regional Compliance Nurse provided in-service to DON/ADON regarding pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed.
- Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool.
- DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool.
- All nurses (LVN/RNs), including PRN nurses, who are not in serviced will not be allowed to provide resident care until training has been completed.
- The Medical Director was notified by the Administrator regarding the immediate jeopardy citation.
- An Ad-hoc QAPI meeting was held by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal.
- DON/Designee will observe wound care to ensure any residents that is receiving wound care receive effective pain management during the procedure.
- DON/Designee will review order listing report in point click care (facility electronic medical record) to see any new wound care orders and ensure that pain management orders are in place.
Failure to Update and Implement Comprehensive Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans were not updated or revised to address significant changes in residents' conditions, including incidents of sexual and physical aggression, as well as abuse allegations. For example, one resident with schizophrenia, dementia, and impulse disorder exhibited repeated sexually inappropriate behaviors and aggression toward others, but the care plan was not updated to include interventions to prevent further incidents on several occasions. Another resident with Alzheimer's disease and major depressive disorder had multiple episodes of verbal and physical aggression toward other residents, including hitting and threatening, yet the care plan was not revised to reflect these behaviors or to implement new interventions after each incident. Several other residents who were victims of resident-to-resident aggression or abuse did not have their care plans updated to address their safety or to reflect the incidents they experienced. In one case, a resident was physically assaulted by another resident, but the care plan was not revised to include safety interventions. Another resident was subjected to inappropriate sexual behavior by a peer, but the care plan did not reflect this event or include measures to protect the resident. Additionally, a resident with significant cognitive impairment and multiple medical diagnoses was discharged before a comprehensive care plan was developed, despite the presence of a baseline care plan. Interviews with facility staff, including the ADON/MDS Coordinator, DON, and Administrator, revealed that care plan updates were delayed due to workload issues and staff covering multiple roles. Staff acknowledged that care plans should be individualized and revised promptly following incidents or changes in condition, but this was not consistently done. Facility policy required care plans to be developed within seven days of the MDS assessment and updated after significant changes, but these requirements were not met for several residents involved in incidents of aggression, abuse, or significant behavioral changes.
Removal Plan
- Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors by ADON/MDS nurse.
- ADON/MDS nurses have been in-serviced on when care plans are due and the importance of completing them in a timely manner by the Administrator.
- Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates.
- MDS coordinator will submit weekly to DON and Administrator care plan list to indicate which care plans are due.
- DON has reviewed all care plans due dates and none are overdue.
- All residents had care plans reviewed by DON and after adjustments were made all care plans are now found to be accurate.
- All residents on secure unit were assessed by DON for injury and signs/symptoms of abuse and neglect.
- Care plan updates will be emailed by the ADON/MDS nurse to each nurses' station when a change occurs or a new focus is added such as but not limited to a change in behavior.
- The administrator will monitor for compliance by being copied on emails to nurse's stations.
- All charge nurses have been notified of this new system by DON.
- Nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions.
- Staff were contacted and in-serviced by DON on abuse, neglect and exploitation, reporting suspected abuse, and intervention methods to include redirection.
- No staff will be allowed to work until this in-service is completed.
Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that further potential harm was prevented while investigations were in progress. Multiple incidents involving resident-to-resident altercations were not properly investigated, and required documentation such as written statements and State Provider Investigation Reports were not completed as per facility policy. For example, one resident was hit in the back by another, another resident was grabbed and scratched, and a third incident involved a resident being pushed to the ground, resulting in injury. In another case, a resident was punched in the face, causing a non-displaced nose fracture. In each of these cases, the facility did not gather written statements or complete the required 5-day investigation reports. The report details that the facility did not analyze the circumstances of these incidents to determine if changes to policies or procedures were needed to prevent recurrence. There was also a lack of review and documentation of corrective actions for these incidents. The Administrator and other staff demonstrated a lack of knowledge regarding the required reporting timeframes and procedures for investigating and documenting abuse allegations. Interviews revealed that the Administrator was unaware of the 2-hour reporting requirement and the necessity of completing and submitting the 5-day investigation report to the state agency. Additionally, the facility's own policy on resident-to-resident abuse, which outlines steps for investigation and reporting, was not followed. Several residents involved in these incidents had significant cognitive impairments or psychiatric diagnoses, such as Alzheimer's disease, dementia, bipolar disorder, and schizoaffective disorder. The incidents resulted in physical injuries, including a nose fracture and a vertebral compression fracture, as well as psychosocial harm. The facility's failure to follow its own policies and regulatory requirements for investigating and reporting abuse led to an Immediate Jeopardy situation, as residents were placed at risk for further harm, unrecognized abuse, and emotional distress.
Removal Plan
- Residents had interventions put in place including separation from other residents when resident to resident altercations occurred.
- Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient.
- Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behaviors were noted.
- Resident #2 & Resident #1 were separated from one another and both sent to the ER, while in the ER staff made referral to inpatient behavioral hospital. Both Resident #2 & #1 were admitted to inpatient behavioral hospital.
- Care plans reviewed and updated as needed for incidents reported.
- Staff separated residents and monitored for any additional behaviors or until placement occurred for residents. When no additional behaviors occurred, residents were removed from monitoring.
- In house psychiatric services are contacted with behavioral incidents for evaluation and additional treatment if needed.
- All staff will be re-educated on the Abuse/Neglect Policy and the procedures for reporting, documenting, and investigating all allegations of abuse or neglect; in-services started by the Administrator, the DON, nurse manager, and department managers and will continue until all staff were in-serviced and no staff will work their scheduled shift until in-serviced.
- Inservices to discuss resident behaviors, how to de-escalate and prevention; all staff must be in-serviced before working their scheduled shift.
- Facility has asked contact from local behavioral hospital to conduct training with staff during mandatory Inservice.
- Inservices related to reporting allegations of abuse to Administrator and DON immediately. Re-education will continue; no staff is to work their scheduled shift until in-services are completed for them.
- RDO trained Administrator and DON on investigating, prevention, and report abuse/neglect allegations.
- RDO in-serviced Administrator/DON with this information.
- Staff in-services were started with staff over completing witness statements, abuse and neglect (timely reporting and types of abuse), safety surveys when state surveyors mentioned these issues.
- Revision of policy and procedure was loaded into staff communication system so everyone who has already signed in-services was made aware of revision to policy.
- Regional Director of operations visits the facility on monthly basis and will follow up with the Administrator/DON with each self-report to ensure investigation of self-reports are completed in timely manner and 3613 is submitted to state with all the documentation gathered with investigation. All communication between monthly visits is to be sent through email.
- In-services for documentation including witness statements and monitoring for required documentation that is needed with incidents, including witness statements and monitoring, all staff will be in-serviced prior to start of shift.
- Nurse manager started Inservice for all Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in-services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that is required for investigation. This information was also included in facility communication for all nurses.
- Department heads started safety survey rounds for residents.
- Charge nurse on secured unit contacting family members for residents that reside on the secured unit to complete safety survey for residents that have impaired cognition; facility is awaiting phone calls from 4 family members where facility left voicemail.
- Resident council scheduled with residents to discuss changes to policy and what is required when these types of allegations are reported.
- Department heads will speak to each resident that did not attend resident council meeting individually and for those that have impaired cognition family members will be contacted.
- The Administrator and DON will personally review all incident reports and abuse allegations within 2 hours of occurrence to ensure timely reporting, investigation, and documentation.
- The Social Services Director and Unit Managers will monitor daily for any new behavioral incidents and report immediately to administration.
- The DON or Designee will complete a daily audit of all incident logs for 30 days, then weekly for 90 days.
- Audit results will be documented and discussed in QA meeting for review and corrective follow-up.
- Any staff member who fails to report, investigate, or document an allegation of abuse appropriately will be subject to disciplinary action up to and including termination.
- The QA Committee will review all incident reports and abuse allegations monthly for 90 days to ensure that each incident is investigated, documented, and reported according to policy.
Failure to Protect Residents from Abuse and Timely Reporting of Incidents
Penalty
Summary
The facility failed to ensure residents were protected from abuse, neglect, misappropriation of property, and exploitation, as evidenced by multiple incidents involving resident-to-resident altercations. Several residents with cognitive impairments and behavioral health diagnoses were involved in physical altercations, resulting in injuries such as a non-displaced nose fracture and a lumbar vertebral fracture. Documentation revealed that one resident was hit in the back by another, another was punched in the face, and another was pushed to the ground, all occurring within a short time frame. Additionally, a resident was grabbed, pulled, and scratched by another resident, leaving visible marks. The facility's records and staff interviews indicated that there were lapses in timely reporting and investigation of these incidents. The Administrator was unaware of the requirement to report abuse within two hours and did not report certain altercations to the state agency, believing that no injury had occurred. There was also a lack of comprehensive care planning for some residents, and staff did not consistently notify supervisory personnel of altercations as required. In some cases, the facility did not complete or document required assessments and care plans for residents involved in these incidents. Interviews with staff and review of documentation showed that staff responses to altercations varied, with some staff intervening and notifying supervisors, while others did not follow established protocols. The facility's failure to protect residents from abuse and neglect, as well as the lack of timely and appropriate reporting and investigation, led to the identification of Immediate Jeopardy. The deficiencies placed residents at risk for continued abuse and negative psychosocial outcomes.
Removal Plan
- Residents were separated from each other and monitored until no further aggressive behaviors were demonstrated.
- Resident #5, #2, and #1 were referred to behavioral unit for inpatient treatment.
- Resident #2 was sent to ER for evaluation and treatment.
- Prior to being admitted to inpatient behavior hospital, #2 & #1 were sent to ER for evaluation and treatment.
- Regional Director of Operations educated Administrator and DON on types of abuse and policy to keep all residents free from abuse and neglect.
- All staff will be re-educated on the facility's Abuse/Neglect Policy by DON, Administrator, department supervisors and nurse manager including identification, prevention, and mandatory reporting requirements.
- In-services will continue; all staff must be in-serviced before starting their shift.
- Documentation of re-education and staff signatures will be completed; all staff will be in-serviced before starting their shift.
- Staff were instructed to immediately intervene and report any signs of resident-to-resident aggression or abuse to the Administrator and DON immediately.
- Department heads started safety survey assessments and will have all safety survey assessments completed on all residents that could give a response at north nurse's station.
- Secured unit charge nurse contacting family members of residents on secured unit to complete safety survey for residents that have impaired cognition.
- Administrator will hold Resident council meeting to discuss abuse/neglect for residents that would like to attend.
- All residents that did not attend resident council will be talked to individually by department heads and family will be contacted for residents that have impaired cognition.
- Medical director notified of Immediate Jeopardy in facility.
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