Citations in Utah
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Utah.
Statistics for Utah (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Utah
A resident with a history of brain hemorrhage and seizures experienced an unwitnessed fall and subsequently showed decreased responsiveness and vomiting. Despite these significant changes, nursing staff delayed notifying the medical provider and waited for the NP to arrive before arranging hospital transfer. The DON later confirmed that immediate physician notification was expected in such cases, and the family expressed concern over the delay. The resident was later found to have a new brain bleed and passed away.
A resident with a history of brain hemorrhage and multiple falls experienced an unwitnessed fall, after which staff initiated neurological checks but failed to document them properly and delayed notifying the medical provider about the resident's change in condition, including vomiting and decreased consciousness. The resident was not sent to the hospital until later in the day, where a brain bleed was diagnosed, and the resident passed away days later. Staff interviews revealed confusion about documentation and escalation procedures, contributing to harm.
Seven public bathrooms accessible to residents were observed to lack call light systems, preventing residents from being able to call for staff assistance while using these facilities. The Director of Maintenance confirmed that these bathrooms were accessible to residents and did not have call lights installed, stating he was unaware of the requirement.
The facility did not ensure that three residents with complex medical conditions were offered the COVID-19 vaccine or that their acceptance or refusal was documented. Record reviews and an interview with the DON confirmed the absence of required documentation for these residents.
Three residents experienced deficiencies in medication management, including administration of blood pressure medications outside of physician-ordered parameters and missed doses of a diabetes medication due to pharmacy and documentation issues. The DON and LPN confirmed that medications were given when they should have been held or were not administered as scheduled, and that proper physician notification and documentation were lacking.
A resident with multiple serious health conditions did not receive several scheduled doses of IV Vancomycin, as ordered for treatment of bacterial arthritis and MRSA. The MAR showed missed or undocumented doses, with no corresponding nurse notes to explain the omissions. Nursing staff confirmed that missed doses should be documented and reported, but this was not done, resulting in a significant medication error.
A resident with multiple health conditions receiving IV Vancomycin had several high trough lab results, but there was no documentation that the physician was notified of these abnormal values. Staff interviews confirmed that the process required physician notification and documentation, but records did not show this occurred.
A resident with multiple complex diagnoses had a STAT KUB x-ray ordered and performed due to abdominal symptoms, but the signed and dated x-ray report was not filed in the clinical record. Staff interviews revealed inconsistencies in the process for handling and filing diagnostic results, resulting in the required documentation being unavailable in the resident's chart.
A resident with MRSA, wounds, and a PICC line was not placed on appropriate contact precautions, as required by facility policy and CDC guidance. Staff were unclear about the differences between Enhanced Barrier Precautions and Contact Precautions, and the resident participated in therapy sessions outside their room without proper signage or PPE protocols in place, resulting in a breakdown of the infection prevention and control program.
A resident with diabetes and other complex medical needs missed several scheduled doses of Trulicity due to pharmacy and supply issues, but the physician was not immediately notified of these missed doses. Documentation showed delays in both medication administration and provider notification, and staff interviews confirmed that the required immediate communication with the physician did not occur.
Failure to Immediately Notify Physician After Resident's Change in Condition Post-Fall
Penalty
Summary
A deficiency was identified when the facility failed to immediately consult with a resident's physician following a significant change in the resident's physical status after a fall. The resident, who had a complex medical history including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. Initial assessment by staff indicated the resident was alert and reported no pain, and the physician, DON, and family were reportedly notified. However, subsequent documentation and interviews revealed that the resident exhibited a decrease in level of consciousness and episodes of vomiting, which were not promptly communicated to the medical provider. Nursing staff continued neurological checks and observed that the resident was less responsive than her baseline, requiring manual opening of her eyes for pupil assessment. Despite these concerning signs, the nurse on duty waited for the Nurse Practitioner (NP) to arrive later in the morning before taking further action, citing previous family concerns about hospital transfers and the resident's DNR status. The NP, upon being notified and assessing the resident, immediately recognized the need for hospital evaluation due to the resident's lethargy and vomiting, and arranged for transfer to the emergency room. Interviews with facility staff confirmed that there was a delay in notifying the medical provider about the resident's change in condition, particularly the decrease in responsiveness and vomiting following the fall. The DON stated that such changes should have prompted immediate physician notification. The family expressed concern that the resident was not sent to the hospital promptly, especially given her history of brain bleeds and falls. The resident was later found to have suffered a catastrophic new brain bleed and passed away several days after the incident. The facility's internal investigation did not address the failure to respond to the resident's change in condition.
Failure to Provide Timely Care and Physician Notification After Resident Fall
Penalty
Summary
A resident with a complex medical history, including traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, epileptic seizures, and obstructive hydrocephalus, experienced an unwitnessed fall in the early morning hours. The resident was found on the bathroom floor by her husband and was initially assessed as alert, with no pain or apparent neurological deficits. Neurological checks were initiated, and the physician, DON, and family were notified via text. However, documentation of the neurological assessment following the fall could not be located in the medical record. Throughout the morning, the resident exhibited a change in condition, including episodes of vomiting and decreased level of consciousness. Staff noted that the resident was more lethargic than usual and required assistance to open her eyes for neurological checks. Despite these concerning symptoms, the resident was not immediately sent to the hospital. The nurse practitioner was notified later in the morning and, upon assessment, determined that the resident needed to be transported to the emergency room. The resident was sent to the hospital by a non-emergent ambulance, where she was diagnosed with a brain bleed and subsequently passed away four days later. Interviews with facility staff revealed inconsistencies in the process for documenting and escalating care for residents with changes in condition following a fall. Staff were unclear about the handling and storage of neurological check forms, and there was a delay in notifying the medical provider of the resident's deteriorating condition. The facility's investigation did not address the resident's change in condition, and the lack of timely intervention and documentation contributed to the finding of harm for the resident.
Lack of Call Light Systems in Public Bathrooms
Penalty
Summary
The facility was found to be inadequately equipped to allow residents to call for staff assistance in public bathrooms, as none of the seven public bathrooms accessible to residents were equipped with a call light system. Observations on 11/20/25 revealed that multiple public bathrooms, including those in the 300 and 400 hallways, near the nurse's station, staff break room, Human Resource office, front desk, Administration hallway, and activities room, did not contain call lights. These bathrooms were not locked, making them accessible to residents at any time. During an interview, the Director of Maintenance confirmed the absence of call lights in these bathrooms and stated that he was unaware of the requirement to have them installed.
Failure to Document COVID-19 Vaccine Offer and Refusal
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine and that their acceptance or refusal was properly documented. During interviews and record reviews, it was found that for three out of five sampled residents, there was no documentation indicating whether the COVID-19 vaccine was offered or refused for the year 2024. The residents involved had significant medical conditions, including quadriplegia, protein-calorie malnutrition, anxiety disorder, type 2 diabetes mellitus, morbid obesity, schizoaffective disorder, major depressive disorder, dementia, and adult failure to thrive. The Director of Nursing confirmed that there was no documentation available to show that these residents were offered or refused the vaccine, and stated that a refusal form should be completed if a resident declines vaccination.
Failure to Adhere to Physician-Ordered Medication Parameters and Timely Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as defined by administration outside of physician-ordered parameters, missed doses, and lack of adequate monitoring. For three residents, there were documented instances where blood pressure medications were administered despite vital signs being outside the prescribed hold parameters. Specifically, one resident with hypertensive chronic kidney disease, hemiplegia, and atrial fibrillation received Metoprolol Tartrate on six occasions when either systolic blood pressure or heart rate was below the physician’s specified threshold for holding the medication. Another resident with diagnoses including orthopedic aftercare, diabetes, and morbid obesity did not receive her prescribed Dulaglutide injections as scheduled for three weeks following admission. The delay was attributed to pharmacy delivery issues and insurance coverage, with documentation showing missed doses and late administration. The resident reported the missed doses, and the nurse confirmed difficulties in obtaining the medication, but there was inconsistent documentation of physician notification and follow-up. A third resident with multiple cardiac conditions, including atrial fibrillation and congestive heart failure, received both Metoprolol Succinate ER and Amiodarone HCl on several occasions when blood pressure or heart rate was below the ordered parameters for holding the medications. Interviews with the DON confirmed that medications should have been held according to the physician’s orders, and that the administration outside of these parameters was not in compliance with the prescribed regimen.
Missed Vancomycin Doses and Lack of Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including bacterial arthritis, MRSA, diabetes, chronic kidney disease, and congestive heart failure, did not receive several scheduled doses of Vancomycin as ordered by their physician. The resident, who had a PICC line for intravenous antibiotics, reported that three doses of Vancomycin were missed. Review of the Medication Administration Record (MAR) showed that on four occasions, Vancomycin doses were either marked with codes indicating 'see Nurse Note' or 'HOLD see Nurse Note,' or lacked any documentation of administration or reason for omission. No corresponding nurse progress notes were found to explain why the medication was not given or held on these dates. Interviews with nursing staff and the Director of Nursing revealed that the expected protocol was to notify the physician of any missed medication doses and document the reason in a progress note. The LPN interviewed stated that a code indicating a missed dose should be accompanied by a detailed progress note, and that missing documentation in the MAR should be flagged for review by nursing leadership. Despite these expectations, there was no documentation to account for the missed Vancomycin doses, resulting in the resident not being free from significant medication errors.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
A deficiency was identified when the facility failed to notify the ordering physician of laboratory results that were outside the clinical reference ranges for one resident. The resident, who had a complex medical history including bacterial arthritis, MRSA, diabetes, chronic kidney disease, congestive heart failure, pain, and edema, was receiving intravenous Vancomycin therapy via a PICC line. Multiple Vancomycin trough levels were reported as high on several occasions, but there was no documentation that the physician was notified of these abnormal results. Interviews with staff confirmed that the process required notification of the physician and documentation in the progress notes when lab results were abnormal. However, review of the resident's records did not show any evidence that the physician was informed of the high Vancomycin trough levels, nor was there documentation of any pharmacy recommendations for dose adjustment. The DON confirmed that such notifications and documentation should have occurred.
Failure to File Signed and Dated Diagnostic Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.
Failure to Implement Proper Contact Precautions for Resident with MRSA
Penalty
Summary
A deficiency was identified when a resident with a history of MRSA septic arthritis, bacteremia, and a PICC line for intravenous antibiotics was not placed on proper contact precautions. The resident had undergone surgical cleaning of both ankles, with the left foot confirmed to have MRSA. Despite the presence of a PPE cart in the room and a magnet indicator on the doorframe, there was no signage specifying the type of transmission-based precautions required. The resident's medical records indicated orders for both Enhanced Barrier Precautions (EBP) and Contact Precautions due to wounds and the PICC line, and the care plan included interventions for EBP related to these conditions. Interviews with staff revealed confusion and lack of clarity regarding the implementation and distinction between EBP and Contact Precautions. An LPN was unable to clearly differentiate between the two types of precautions or specify the required PPE for each. The Director of Rehabilitation was unaware that the resident was on any transmission-based precautions and allowed the resident to participate in therapy sessions in the gym, stating that if the wound was contained, gym attendance was permitted. The DON confirmed that a number 6 magnet was used to indicate EBP, but that Contact Precautions would require additional signage, which was not present for this resident. Facility policies and CDC guidance reviewed during the survey specified that residents with MRSA infections should be placed on Contact Precautions, with clear signage and appropriate use of gowns and gloves upon room entry. The lack of proper signage, inconsistent staff knowledge, and failure to implement the correct precautions for a resident with an active MRSA infection led to the deficiency. The resident was observed participating in group therapy without the required precautions in place, further demonstrating the facility's failure to maintain an effective infection prevention and control program.
Failure to Immediately Notify Physician of Missed Diabetes Medication
Penalty
Summary
A deficiency was identified when the facility failed to immediately inform or consult with a resident's physician regarding a significant change in the resident's treatment, specifically related to the administration of Trulicity (Dulaglutide) for diabetes management. The resident, who had diagnoses including orthopedic aftercare following amputation, Type 2 diabetes mellitus, and morbid obesity, reported missing three weeks of Trulicity injections upon admission. Medical record review showed that the medication was not administered as scheduled on multiple occasions due to pharmacy delivery issues and lab results, with documentation indicating delays and missed doses. Despite these missed doses, there was no immediate notification to the resident's physician at the time the medication was unavailable. Provider notification occurred 24 hours after a scheduled dose was missed, and in other instances, the medication was either awaited from the pharmacy or arrangements were made for a family member to bring it in. Interviews with facility staff, including an LPN and the DON, confirmed that the physician was not promptly notified as required when the medication was not available, and the DON was unaware that multiple doses had been missed.
Some of the Latest Corrective Actions taken by Facilities in Utah
The facilities implemented several corrective actions to address the safety and supervision deficiencies.
- The facility assessed the resident for injuries, contacted police upon suspicion, and updated care plans as needed. Staff received training on abuse prevention and elopement protocols. (J - F0600 - UT)
- The Director of Nursing audited residents with medical devices to ensure proper care planning and staff training. Staff were trained on safe transfers and accident prevention, including appropriate transfer techniques. The Administrator ensured transportation staff were trained and competent in securing residents during transport. (J - F0726 - UT) (J - F0689 - UT)
- The facility partnered with an organization to provide training and new protocols for resident transport. Transportation staff were reeducated on proper securement procedures and underwent competency evaluations. The Quality Assurance Performance Improvement Committee approved the updated driver safety program and implemented ongoing audits. (G - F0689 - UT)
- The facility audited residents' transfer statuses to ensure appropriate equipment was used. Staff received re-education on changes in condition, appropriate lifts, and safe transfer methods. Department heads conducted spot checks to verify compliance with transfer protocols. (G - F0689 - UT)
Failure to Provide Timely Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in care. Resident 46 experienced ongoing emesis and abdominal pain, but the facility did not ensure timely monitoring or intervention. Despite receiving a stat order for an ultrasound, the facility delayed contacting the contracted radiology provider, resulting in a significant delay in obtaining the ultrasound. The resident continued to experience symptoms without adequate assessment or communication with the physician, ultimately leading to the resident's death. Resident 46 had a complex medical history, including hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Despite these conditions, the facility staff failed to document and communicate the resident's change in condition effectively. Multiple staff members observed the resident's deteriorating condition, including vomiting and abdominal pain, but there was a lack of coordinated response and communication with the medical team. Similarly, Resident 298, who had a history of dementia, hypertension, and acute kidney failure, did not receive timely diagnostic testing for a suspected deep vein thrombosis. The facility canceled a scheduled appointment and failed to ensure the ultrasound was performed promptly. This lack of timely intervention and communication with healthcare providers contributed to the deficiency in care for both residents.
Removal Plan
- The community management team implemented a morning Standup meeting with Nursing to get report from previous day's activities/concerns. If changes in condition are noted from communication notes, DON or ADON will verify MD team had been notified and if notification has not been made will do so at that time. Consultants will attend morning meetings when in-person and participate in random morning meetings when offsite to ensure compliance.
- The nursing team implemented a new shift communication form that will be relayed at shift change with oncoming nurse for concerns/follow-up items still pending at shift change. All forms will be left in the drawer at nurse's station for management review at the next morning standup meeting. Consultants will provide training on this process.
- A new CNA communication program/sheets implemented as a way for CNAs to communicate with oncoming shift and report to nurse. Sheets will be collected daily and reviewed during the daily standup meeting with department managers. Consultants will provide education and training on this process.
- Nursing implemented a new Communication and Follow-Up book that will remain at the nursing station. The book is a duplicate copy book with highlights and follow-up items from the previous day. The original will be removed and reviewed at daily manager Standup meeting. Consultants will provide education and training on this process.
- Communication improvements made between the building and MD team by adding the DON and Administrator to the secure messaging app between the MD group and Facility. Areas of concern or issues that arise will be addressed in the manager stand-up meeting.
- Representatives from the consulting organization reviewed and assessed the facility's policies and procedures regarding changes in resident condition. The consultants provided the community with a change of condition policy to adopt. The consultants provided education and training with licensed nursing and nursing assistants.
- Facility in coordination with the consulting organization, the consultants will complete record reviews of all residents to ensure no resident has experienced a change in condition not previously identified. Any findings of change of condition will be reported to the resident's attending physician and the resident's representative. This information will be communicated with the DON and Administrator at the manager stand-up meeting.
- The consultants ongoing will review daily progress notes to ensure documented changes of condition are timely identified and action steps are taken with resident changes of condition.
Resident Found in Locked Therapy Room with Alleged Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy citation. A resident with a history of dementia and cognitive impairments was found missing by staff, and after a search, was discovered exiting a locked therapy room. The resident made statements indicating that a male staff member engaged in sexual actions with her. The therapy room was inaccessible to staff, and the resident was found pale, nauseated, and disoriented, with therapy paperwork in hand. Interviews with staff revealed that the therapy room was locked, and the resident was missing for approximately 20 minutes. Staff observed the resident exiting the therapy room, appearing sick and disoriented. The resident later disclosed to staff that she and a male staff member attempted to engage in sexual activity, which was reportedly consensual according to the resident. However, the resident's cognitive impairments raised concerns about her ability to consent. The male staff member, a Physical Therapy Assistant, was found in the facility after hours, contrary to previous instructions. Staff reported that the therapy room was usually unlocked, and the male staff member's presence in the facility after hours had been a concern. The facility's failure to ensure the safety and security of the resident, as well as the lack of access to the therapy room, contributed to the deficiency.
Removal Plan
- Resident and staff member were separated.
- Police contacted upon suspicion.
- Resident assessed; no injury noted.
- Notification to Physicians, POA, Incident reported by administrator to DHS, APS, Ombudsman.
- Resident interviewed with administrator.
- Hospital evaluation completed, no trauma noted.
- Resident care plan reviewed and updated as needed.
- Provider to assess/evaluate residents including medication review.
- Social Services wellness visits to be completed for resident and PRN.
- Behavioral health visit requested with local mental health provider.
- Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator.
- Therapy staff member was questioned and released by the police, pending potential charges.
- Employee file was reviewed.
- Therapy staff member will not return to the facility.
- Regional Director of Operations spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator.
- Facility will ensure the therapy staff working in the facility have background checks (DACS) that are connected to the facility.
- All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations.
- Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart.
- Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator.
- Administrator, DON and RNC reviewed Abuse & Neglect Policy.
- Administrator, DON and IDT were educated by RNC regarding Abuse & Neglect Policy.
- Administrator/DON/designee will complete Abuse & Neglect education with all staff.
- Education including post-test initiated for all facility staff on Abuse/Neglect.
- All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting.
- The DON/designee will review incidents of sexually inappropriate behavior to ensure appropriate interventions are implemented and no trends are noted.
- The Administrator/designee will conduct random resident & staff interviews to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported.
- The facility administrator/designee will do random facility visits during off hours to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility.
- The Administrator/designee will review employee files (including contracted therapist) to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility.
- Medical Director was informed of the incident and QAA Review & Recommendations.
- Results will be reported to the QAA committee from monitoring and follow-up.
Failure to Prevent Sexual Abuse and Elopement
Penalty
Summary
The facility failed to prevent an instance of sexual abuse between two residents and neglected to provide the necessary supervision to prevent the elopement of another resident. Resident 269, who had severe cognitive impairment and a history of wandering, was found naked from the waist down on top of Resident 270, who was also cognitively impaired and nonverbal. The incident occurred when the staff responsible for monitoring the memory care unit were occupied with other tasks, leaving the residents unsupervised. This lack of supervision allowed Resident 269 to enter Resident 270's room and engage in inappropriate behavior, which was only discovered when therapists were searching for Resident 269 for a therapy session. The facility's failure to monitor Resident 269's wandering behavior and provide adequate supervision directly led to the incident of sexual abuse, which was verified by the facility's investigation. In a separate incident, Resident 17, who had a history of wandering and severe cognitive impairment, eloped from the facility. The resident was found and returned by a police officer. The facility's records indicated that Resident 17 had been assessed as a high risk for wandering and required frequent safety checks. However, the facility failed to implement a coordinated plan to supervise the resident's whereabouts, leading to the elopement. The receptionist, who was assisting another resident outside, believed that Resident 17 eloped through the front door during this time. The facility's lack of a coordinated plan and failure to monitor Resident 17's wandering behavior resulted in the resident's elopement. Both incidents were determined to be noncompliant and constituted immediate jeopardy. The facility's failure to prevent the sexual abuse of Resident 270 and the elopement of Resident 17 highlighted significant lapses in supervision and monitoring of residents with known wandering behaviors and cognitive impairments. These deficiencies were identified through interviews, record reviews, and witness statements, which documented the events leading to the incidents and the facility's inadequate response to the residents' needs for supervision and safety.
Removal Plan
- Resident was assessed for injury; no injuries were found.
- Facility representative spoke with family who reported that she had done this type of thing at home.
- Resident was determined to be a high risk for further elopements and would need to be moved to the secure unit. Resident was transferred to the secure unit to prevent further elopements.
- IDT reviewed the elopement.
- A training was conducted for the all staff meeting. Clinical training topics included labs, abuse reporting, and elopement prevention.
- Facility IDT met to review elopement process.
- Elopement binder was created for all high-risk residents on Cambridge.
- CNA Coordinator was given instructions to create tools for the staff, including a task sheet to alert staff of high-risk behaviors for residents and elopement sheets for the elopement binder.
- CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents.
- Administrator/Designee began holding meetings with CNA coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit.
- QAPI committee reviewed the events and identified the need for further interventions for elopement/abuse prevention.
- QAPI committee began creating care kits for memory care residents to decrease boredom, exit seeking, and help residents who were up at night.
- Residents were separated, and the abuse investigation was initiated.
- The police were notified, CMS was notified.
- The resident was placed on 1:1 with the intention to remain until the investigation was complete and interventions could identify how to prevent recurrence.
- The victim was moved off the unit.
- An internal meeting was held to review the investigation with the Regional Nurse Consultant, the Director of Clinical Services, the Corporate LCSW, the Facility Administrator, and Director of Nursing.
- Director of Nursing conducted an in-service with facility staff on Abuse Prevention with a post-test validation.
- The perpetrator was reviewed by the Behavioral Health Facility Committee to validate interventions were effective and further abuse prevented.
- Corporate LCSW provided a training with the Social Services Department on Sexual Intimacy in the LTC setting, Assessing Capacity to Consent, Care Planning, and appropriate Documentation.
- Corporate LCSW came to the facility and assessed the Perpetrator and reviewed the interventions in place.
- Cameras were set up to enhance visibility in the unit for staff.
- Computers in the unit were connected to be able to view halls for when CNAs were busy in rooms.
- Facility reviewed staffing patterns on the unit to validate that there was proper supervision on the unit.
- An investigation was conducted and found that the abuse program was not being run in accordance with facility policy and procedure.
- The administrator was terminated.
- A facility manager took over the facility with significant oversight of the RVP/Designee.
Inadequate Staff Training Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care for a resident, leading to a series of incidents that compromised the resident's well-being. A resident was transported in a facility van without proper securement of their wheelchair, resulting in the resident falling backward and sustaining a hyperextension injury to the neck. This incident led to a diagnosis of central cord syndrome and edema at the C6 and C7 levels of the cervical spine. The facility's failure to provide adequate training for staff responsible for transporting residents was a significant factor in this incident. Following the transport incident, the resident's care continued to be compromised. Upon returning to the facility, the resident's cervical collar, which was ordered to be worn at all times, was removed by CNAs during grooming and bathing. This removal occurred without proper supervision or understanding of the potential risks, as the CNAs were not adequately trained or informed about the necessity of the cervical collar. The resident was then unsuccessfully transferred to bed, resulting in the resident being assisted to the floor, further indicating a lack of competency in safe transfer techniques among the staff. The report highlights that the facility did not conduct proper orientation and training for newly hired nurse assistants and CNAs, which contributed to the inadequate care provided to the resident. The CNAs involved in the incidents were not properly trained on the use of medical devices such as the cervical collar, nor were they adequately supervised during critical care activities. This lack of training and supervision was a direct cause of the deficiencies observed, leading to the resident's compromised safety and well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Facility's Failure to Ensure Resident Safety Leads to Multiple Incidents
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in multiple incidents of harm and immediate jeopardy. One significant incident involved a resident who was improperly secured in a wheelchair during transport in the facility van, leading to a fall that caused a hyperextension injury to the cervical spine, resulting in central cord syndrome. The resident's condition was further compromised when CNAs removed the cervical collar during grooming and bathing, which was against the medical order for the collar to be worn at all times. This lack of adherence to safety protocols and inadequate staff training on securing residents during transport and handling medical devices contributed to the resident's injury and subsequent complications. Additionally, the facility experienced several other incidents indicating a failure to maintain a hazard-free environment and provide adequate supervision. These included a resident sustaining a fractured hip after multiple falls, another resident tripping over a broken structural column, and a resident being unsafely discharged and found wandering. There were also instances of residents eloping from the facility, a resident being injured by another resident with a razor, and a resident being hit by a meal cart. These events highlight the facility's systemic issues in identifying and mitigating accident hazards and ensuring resident safety. The facility's deficiencies were compounded by inadequate staff training and oversight. The CNA Coordinator responsible for the transport incident had not received proper training on securing residents in the transport vehicle. Furthermore, the facility's documentation practices were insufficient, as evidenced by the lack of monitoring orders for the cervical collar and incomplete incident reports. These deficiencies underscore the need for comprehensive staff training and robust safety protocols to prevent future incidents and ensure resident well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Resident Injury Due to Improper Securement During Transport
Penalty
Summary
The facility failed to ensure that a resident received the necessary supervision and assistance devices to prevent an accident during transportation. Specifically, a resident was not properly secured in a facility vehicle, leading to the resident sliding out of their wheelchair and sustaining a femur fracture. The incident occurred when the transportation driver had to brake suddenly, and it was later revealed that the lap belt was not secured on the resident. The resident involved had a medical history that included diabetes mellitus type 2, hypotension, muscle weakness, and required assistance with personal care and mobility. The resident used a wheelchair and had moderately impaired cognition, as indicated by a BIMS score of 11. On the day of the incident, the resident was being transported back from a doctor's appointment when the accident occurred, resulting in injuries that required hospitalization. The transportation driver admitted to neglecting to secure the lap belt, although the wheelchair was harnessed at four points. The incident was reported to the Survey State Agency, and the facility's investigation confirmed the oversight in securing the resident properly. The resident was evaluated by a facility nurse and emergency medical services were called, leading to the resident's transport to an acute care hospital where a left femur fracture was diagnosed.
Removal Plan
- The facility entered into an agreement with an organization to implement and provide training and new protocols to transport facility residents.
- All staff who performed transportation services for the facility were reeducated on proper securement of residents during transport, which included training videos produced by the contracted organization.
- Transportation staff attested to the completion of the training by signing training records.
- Transportation staff were required to complete a post-training test.
- All staff members who performed transportation services were required to read and sign the Fleet Safety Program book.
- Staff members were interviewed regarding safety during transportation.
- Administrative staff interviewed residents to determine if there were additional concerns about safety during transportation.
- The facility's Quality Assurance Performance Improvement (QAPI) Committee approved the updated driver safety training program.
- The transportation supervisor will audit the transport of each driver daily for 2 weeks, followed by audits on 3 random days of the week for 1 week, with an audit 1 day per week for 1 week.
- The transportation supervisor will perform ongoing random audits.
- The transportation supervisor or designee will validate transportation driver's pre and post-securement, documenting the results every week for 4 weeks then bi-weekly for 2 weeks, and 3 random audits every month thereafter.
- The transportation supervisor will report any trends or concerns to the QAPI committee for review for 90 days.
- Any discrepancies will be addressed at time of discovery.
Inadequate Supervision and Improper Transfer Method Result in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices for a resident, leading to an accident. Resident 217, who had a history of cerebrovascular accident, right bundle branch block, heart failure, and major depressive disorder, was dependent on staff for transfers due to his inability to stand. Despite this, on a specific date, CNA 4 used a sit-to-stand device to transfer the resident, contrary to the care plan that required a Hoyer lift with two-person assistance. During the transfer, the resident was unable to bear weight, causing his arms to move upward, but the transfer was completed without immediate signs of pain. Subsequently, the resident was found to have a swollen and bruised left shoulder, which was later diagnosed as a fracture of the left humeral surgical neck. The facility's investigation revealed that the injury likely occurred during the improper transfer by CNA 4. The resident's condition, compounded by his non-verbal status due to the cerebrovascular accident, meant he could not communicate pain effectively, delaying the recognition of the injury. The facility's documentation and communication were also found lacking. The weekly skin assessment inaccurately reported no skin issues, despite bruising being observed earlier. Additionally, the bruising was not reported to management until two days after it was first noticed. This delay in reporting and the initial use of an inappropriate transfer method contributed to the harm experienced by the resident.
Removal Plan
- Audit all residents with current sit to stand transfers to ensure the current lift being used is appropriate for the resident status.
- Perform re-education 1:1 in huddles or over the phone regarding change of condition, bruising, range of motion, and which lift is appropriate for resident current condition.
- Complete audits with department heads on spot checking rooms to ensure staff members are using the appropriate lift with two-person transfer.
- Make unit managers aware of any changes with therapy evaluation with the lifts.
Explore Popular Searches
