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 cerebral palsy, dysphagia, severe protein-calorie malnutrition, and cachexia was receiving continuous NG tube feeding with Jevity 1.2 at a prescribed hourly rate. During observation, the tube feeding bag was found labeled only with a date and staff initials, without the required start time. In interviews, an RN stated that nurses are expected to label tube feed bags with the date, start time, and initials, and the DON confirmed that bags should include the complete date and time started and be signed by the nurse, showing that the observed practice did not meet professional standards of quality.
A resident with dementia, impaired mobility, and bowel/bladder incontinence remained in soiled clothing for over an hour and a half after staff were notified of the need for a brief change. The care plan required incontinence briefs to be changed every two hours and as needed, but multiple staff entered or passed by the room for other tasks, including meal delivery and activity calendar checks, without providing incontinence care. The resident, who had severely impaired cognition, initially believed her brief had been changed but then realized it had not. Incontinence care was finally provided only after a prolonged delay, despite established rounding practices and communication from activities staff to nursing.
A resident with Type 2 DM and restless leg syndrome reported having open leg sores for at least a week, with bleeding through bandages onto socks, yet there was no documentation of leg wounds, assessments, or wound care orders in the medical record. Observation showed a discolored lower leg with a saturated bandage leaking serosanguineous drainage and additional uncovered draining areas. Although an RN later performed a dressing change and stated the wounds needed to be documented for daily assessment, no timely wound care orders or progress notes were entered, and the resident reported that dressings were not changed on a subsequent day. This occurred despite a care plan goal for intact skin and interventions requiring daily body checks and immediate nurse notification of any new skin breakdown.
A continent resident with mobility limitations was provided a PureWick external catheter for several weeks while non‑weight bearing, with surveyors observing a bedside suction canister containing dark amber fluid and the resident reporting the device was changed only a few times per week. Record review showed no physician order or directions for use and no care plan addressing the PureWick, despite staff acknowledging that such a device requires an order and should be care planned. CNAs learned of the device use only through CNA report, one RN reported no facility training and uncertainty about change frequency, while another RN described expected change and cleaning intervals, and the DON confirmed the device had been used without an order or inclusion in the care plan.
A resident with gait instability and muscle weakness was seen by a physician on multiple occasions, as documented in nursing notes, but the corresponding physician progress note for at least one visit was missing from the medical record, leaving no documented evaluation of the resident’s condition or total program of care, including meds and treatments. The HIM Director reported that one physician does not write or dictate notes in the facility record, requiring staff to request progress notes from the physician’s office, and the DON described a process in which a form and worksheet with orders are sent back with the resident, with detailed notes obtained later and scanned into the chart, noting it is difficult to obtain these progress notes.
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an NG feeding tube and significant comorbidities, including cerebral palsy, dysphagia, and severe protein-calorie malnutrition. Surveyors observed an RN reconnect an uncapped feeding tube that had been touching a metal IV pole while wearing only gloves and no gown, despite an EBP sign on the door. On another occasion, a speech therapist provided multiple PO trials and repositioned the resident while wearing gloves but no gown. In interviews, the RN, CNA Coordinator, and DON all confirmed that residents with feeding tubes require PPE, including gowns and gloves, when handling tube feedings or feeding the resident under EBP.
A resident with stage 4 CKD, a distal femur fracture, and a non–weight-bearing order for the left leg was being transferred from bed to a bedside commode using a walker and gait belt when the assisting CNA left mid-transfer to answer other call lights, leaving the resident unattended. The resident, who was on Eliquis and had oxygen tubing in place, attempted to reposition the walker and sit further back on the commode, became tangled, and fell forward to the floor, sustaining a nasal abrasion and a minimally impacted nasal bone fracture confirmed by CT.
A resident with complex cardiac, renal, and nutritional conditions received evening TPN ordered with pharmacy instructions that conflicted between the electronic order summary and the pharmacy label regarding total volume, rate, and duration. An agency RN initiated the TPN, reported not finding an IV pump, and manually regulated the infusion via roller clamp instead of using the pump that was later confirmed to be in the room. The TPN, which was ordered to infuse over many hours with tapering, was instead delivered over roughly 3 hours, and the oncoming RN later found the bag empty and connected directly to the PICC line without the pump. Subsequent documentation showed marked changes in the resident’s neuro status and vital signs, including lethargy, altered mental status, elevated HR and BP, hyperglycemia, and complaints of chest pain, leading to EMS transfer and hospital admission. The facility’s investigation substantiated that the TPN was administered incorrectly as a bolus, and the PN policy requiring controlled, tapered infusion was not followed, while the transfer documentation did not note the TPN bolus when the resident was sent to the hospital.
A resident with sepsis and kidney stones was managed on PRN morphine for pain, but two concurrent PRN orders for morphine 15 mg (0.5 tablet q3h and 1 tablet q3h) were entered, creating a potential daily dose of up to 180 mg without clarification. Despite documentation of slurred speech, lethargy, low O2 sats, cough, and shortness of breath, and a provider note attributing intermittent dysarthria to morphine and indicating the need to reduce dosing unless pain exceeded 4, no updated morphine order was found. Nursing staff continued to administer 15 mg doses based largely on the resident’s requests and subjective pain scores, without resolving the conflicting orders or consistently consulting the provider, and the resident was ultimately transferred to the ED in critical condition, where opiate toxicity was diagnosed and treated with naloxone.
The facility failed to complete and document thorough investigations into two serious injury incidents reported as potential abuse, neglect, exploitation, or mistreatment. In one case, a resident had an unwitnessed fall, later developed left leg weakness, and was found by X-ray to have a distal femoral metaphasis fracture, but no investigation documentation was available. In another case, a resident sustained a head injury during a hoyer lift transfer, later showed a change in neurological status, and was found by CT to have a subdural hematoma, yet no five-day summary report or investigation could be located, despite acknowledgment that such investigations were required to rule out neglect or abuse.
Incomplete Labeling of Continuous Tube Feeding Bag
Penalty
Summary
The deficiency involved the facility’s failure to ensure that enteral feeding services met professional standards of quality for one resident. The resident had diagnoses including cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia, and had a physician’s order dated 1/25/26 for continuous NG tube feeding with Jevity 1.2 at 30 mL per hour over 24 hours. On 1/26/26 at 12:10 PM, observation of the resident’s tube feeding revealed that the feeding bag was labeled only with the date “1/26” and two-letter staff initials, without the time the feeding was started. In an interview on 1/28/26 at 9:51 AM, RN 1 stated that night shift nurses were responsible for changing the tube feed bags and that bags should be labeled with the date, the time the tube feed was started, and the nurse’s initials, and acknowledged that without complete labeling, the start time of the feeding could not be known. On 1/29/26 at 8:13 AM, the DON confirmed that tube feeding bags were expected to be labeled with the complete date and time started and signed by the initiating nurse, indicating that the observed labeling did not meet the facility’s expectations.
Failure to Provide Timely Incontinence Care After Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident, resulting in the resident remaining in soiled clothing for one hour and 33 minutes after staff were notified. The resident had diagnoses including COPD, muscle weakness, and dementia, with an MDS BIMS score of 7 indicating severely impaired cognition. The resident’s care plan identified bowel and bladder incontinence related to impaired mobility and dementia, with a goal to remain free from skin breakdown due to incontinence and interventions specifying incontinence brief use with changes every two hours and as needed. On the day of the incident, the resident was observed at 11:55 AM with soiled pants as she was assisted into her room, and a staff member used an earpiece to request assistance for a brief change. Subsequent continuous observations showed multiple staff entries into and past the resident’s room without providing the needed incontinence care. At 12:02 PM, a CNA entered only to ask about meal location and then exited without checking or changing the brief. At 12:21 PM, another CNA walked by the room without entering. At 12:55 PM, the resident reported she believed her brief had been changed, then checked and realized it had not. At 1:23 PM, a CNA entered only to deliver a meal tray and left, and another staff member entered to check the activities calendar and exited without addressing incontinence needs. At 1:28 PM, staff brought the roommate into the room and a CNA brought in a Hoyer lift and closed the door; by 1:38 PM, CNAs exited the room and indicated the resident was “all good,” and at 1:39 PM the resident was observed in a recliner with different pants, indicating the change had finally occurred. Interviews confirmed that rounding was expected every one to two hours, that the resident commonly had a wet brief after activities, and that activities staff radioed nursing when a brief change was needed, but the incontinence care for this resident was not provided in a timely manner after the initial notification.
Failure to Assess, Treat, and Document Resident Leg Wounds per Standards and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and the resident’s care plan for skin integrity. A resident with Type 2 diabetes and restless leg syndrome reported having open sores on his lower leg for at least a week and stated he had informed a nurse, who applied bandages, but he continued to bleed through the bandages onto his socks. On observation, the resident’s right lower extremity below the knee was reddish-purple with a large bandage saturated with serosanguineous drainage leaking onto his sock, and two additional draining areas were uncovered. There was no documentation in the medical record of any leg wounds, wound assessments, or wound treatment orders, despite the resident’s report that bandages had been applied previously. Further observations and interviews showed that the resident’s wounds were not being consistently assessed or documented. During a dressing change, an RN told the resident she needed to ensure his wounds were documented in the computer to be assessed daily, but there was still no wound care order or progress note documenting his skin condition in the record the following day, and the resident reported that no nurse had assessed or changed his bandages that day. The resident’s care plan, initiated months earlier, included a goal for intact skin and interventions such as daily body checks and immediate nurse notification of any new skin breakdown, redness, blisters, bruises, or discoloration, but these interventions were not effectively implemented or documented for this resident’s leg wounds. Interviews with nursing leadership confirmed that required steps such as documenting skin changes, entering wound care orders, and completing appropriate notes were not carried out as expected for this resident.
Unordered and Uncareplanned Use of PureWick Device for Continent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a continent resident received appropriate services to maintain continence and that the use of a PureWick external catheter was properly ordered and care planned. Resident 53 was admitted with unsteadiness on feet, difficulty in walking, and muscle weakness, and reported being continent of urine upon admission. During a surveyor observation, a suction canister with dark amber fluid and suction tubing was noted at the bedside, and the resident stated she had been non‑weight bearing for a few weeks and was given a PureWick catheter so she did not have to get up to use the toilet. She reported that staff changed the PureWick device a few times a week. Review of the medical record showed no physician order for the PureWick device and no directions for its use, and the resident’s care plan did not include the PureWick. Staff interviews confirmed that the resident had been continent when first at the facility and later began using a PureWick device, with a CNA learning of this only through CNA report and noting the resident also wore briefs. The CNA Coordinator acknowledged there was a resident using a PureWick and that this was new for the facility, stating CNAs had been trained and could ask questions. RN 2 confirmed the resident had used the PureWick for a couple of weeks due to being non‑weight bearing and not wanting frequent brief changes, and stated that PureWicks should have a doctor’s order, but she had not received facility training on its use and was unsure how often it should be changed. RN 3 stated the device should be changed every 24 hours, the canister cleaned once a week, and that use of a PureWick should be care planned. The DON reported the resident had used the PureWick for about two weeks for dignity while bedbound and non‑weight bearing, acknowledged that a doctor’s order was required and that the resident did not have one, and stated that the use of a PureWick should be care planned.
Failure to Ensure Physician Review and Documentation of Resident’s Total Program of Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician reviewed a resident’s total program of care, including medications and treatments, and documented an evaluation of the resident’s condition at required visits. Resident 53, admitted with unsteadiness on feet, difficulty in walking, and muscle weakness, had nursing notes indicating that a physician saw the resident on two occasions. A nursing note dated 12/4/25 documented that the resident was seen by a physician, and another nursing note dated 1/13/26 documented that the physician reviewed labs and medications and answered questions, with a plan to continue monitoring. However, the physician progress note for the 1/13/26 visit could not be located in the resident’s medical record, and there was no documented physician evaluation of the resident’s condition and total program of care, including medications and treatments, and no documented decision about the continued appropriateness of the current medical regimen. During interviews, the HIM Director reported that one of the facility physicians does not write or dictate any medical records for the residents he sees, requiring the facility to call the physician’s office to request progress notes, and stated that it was hard to track resident records because the physician did not write in the resident’s medical record. The DON explained that the facility sends a form with the resident for the physician to write what was done at the appointment and that, if more detailed notes are needed, staff must call the physician’s office to obtain progress notes, which are then scanned into the resident’s record. The DON also stated that the physician sends back a worksheet with orders and that it is difficult to obtain progress notes from this physician. These practices resulted in missing physician documentation for Resident 53’s visit and a lack of evidence that the physician reviewed and evaluated the resident’s total program of care as required.
Failure to Follow Enhanced Barrier Precautions for Resident With NG Feeding Tube
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and safe handling of a nasogastric (NG) feeding tube for one resident. The resident was admitted with cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia, and had an NG feeding tube with continuous tube feeding. Surveyors observed that the resident’s room had an EBP sign on the door, but on one occasion the tube feeding pump was beeping with an inactive status and one end of the feeding tube was uncapped and touching a metal IV pole. A registered nurse entered the room, donned only gloves, picked up the uncapped end of the feeding tube from the IV pole, and reattached it to the NG tube without wearing a gown, despite the resident being on EBP. On another occasion, a speech therapist entered the same resident’s room, donned gloves but did not wear a gown, and conducted a feeding session. The therapist knelt on the floor and administered multiple trials of different fluids and foods, adjusted the resident in bed, and then exited the room without donning a gown at any time. Speech therapy documentation confirmed that the resident received multiple oral trials of yogurt, apple juice, and a peach, with noted anterior loss of bolus and difficulty determining safety due to the resident’s inability to hold the bolus in the oral cavity. In interviews, the RN, CNA Coordinator, and DON all stated that residents with feeding tubes or other indwelling devices required PPE including gowns and gloves, and that EBP should be followed for residents with feeding tubes, with gowns required when handling tube feedings or feeding the resident. These observations and statements show that staff did not follow the facility’s EBP requirements for this resident.
Resident Fall During Unsupervised Transfer to Commode
Penalty
Summary
A deficiency occurred when a resident with a non–weight-bearing order for the left lower extremity and a history of a distal left femur fracture was not provided adequate supervision during a transfer. The resident, who also had stage 4 chronic kidney disease and was on Eliquis, used a walker and was to bear weight only on the right leg during transfers, with a gait belt in use. While the resident was being assisted from bed to a bedside commode, the CNA providing assistance left in the middle of the transfer to respond to other call lights, before the resident was fully seated. During this unsupervised moment, the resident attempted to complete the transfer independently, became tangled while positioning the walker, and fell forward to the floor, landing on her face. The resident reported that she had gotten up to use the bedside commode and was trying to sit further back when she became tangled and fell. The fall resulted in a superficial abrasion over the nose and a minimally impacted anterior nasal bone fracture, with CT imaging showing mild soft tissue swelling over the anterior nasal bridge and no acute intracranial findings. At the time of the incident, the resident also had oxygen tubing in place and the nurse assigned to the resident was charting across the room.
Unsafe TPN Administration via Gravity Drip and Order Discrepancies
Penalty
Summary
The deficiency involves the unsafe and inappropriate administration of TPN/IV fluids to a cognitively intact resident with multiple complex medical conditions, including CHF, chronic pulmonary edema, chronic kidney disease, kidney transplant status, malnutrition, intestinal fistula, and electrolyte disorders. The resident had an order for evening TPN with pharmacy instructions specifying a compounded volume of 1800 ml, including start and end taper periods, and a total run period of 16 hours. However, the pharmacy label on the TPN bag directed infusion of 1800 ml at 125 ml/hr over 12 hours, and there were discrepancies between the pharmacy order summary (with tapering start and end rates and volumes) and the label directions. The DON later acknowledged that the label directions did not match the calculated infusion time for the stated volume and rate and that there was confusion in how the order was written. On the evening of the incident, an agency RN initiated the resident’s ordered TPN infusion between approximately 7:30 PM and 8:00 PM. The agency RN reported that an IV pump was not present in the room and manually calculated the drip rate, regulating the infusion via the roller clamp and counting drips per minute, rather than using an IV pump. It was later confirmed that an IV pump was in fact present in the room. The agency RN did not document or report the duration of infusion used to calculate the drip rate. Between 10:00 PM and 10:30 PM, the agency RN reported that the TPN bag was about half full before leaving the shift. At around 10:00 PM, the oncoming facility RN assumed care of the hallway and later, at approximately 11:01 PM, entered the resident’s room and found the TPN bag empty, connected directly to the PICC line and not routed through the IV pump. The progress note documented that the resident had already received the full TPN volume even though it was scheduled to run over 12 hours, and the facility’s abuse investigation determined that the TPN had infused over about 3 hours and 15 minutes instead of the ordered 12 hours. Following the rapid infusion, the resident’s condition changed. At about 11:01 PM, the resident’s blood sugar was documented as 450, and vital signs and neuro checks were performed, with subsequent neurological assessments showing elevated HR, elevated BP, increased RR, and progressive changes in level of consciousness and motor response from baseline over the night and into the morning. The resident became lethargic with altered mental status, was more difficult to arouse, and later complained of chest pain, headache, nausea, and confusion. A physiatry follow-up note described the resident as lethargic, arousable only to loud voice and tactile stimulation, and reporting constant sharp chest pain. EMS was called later that morning due to chest pain, low BP, fever, and high HR, and the resident was transferred to the hospital, where she was noted to be febrile, tachycardic, initially hypotensive, and confused, with differential diagnoses including sepsis and line sepsis. The facility’s emergency transfer form did not document that the resident had received a TPN bolus the prior night, and the hospital documentation did not reflect that the TPN bolus and associated change in condition had been communicated. The facility’s own investigation substantiated that the resident received TPN incorrectly as a bolus over a short period rather than as ordered. The facility’s PN policy required that PN be tapered up over 1–2 hours, run at a set rate for a determined time, and then tapered down over 1–2 hours, and specifically stated that PN should never be stopped suddenly and that tapering is needed to prevent hypoglycemia. The pharmacy order summary for this resident’s TPN included start and end taper periods and a total run period of 16 hours, but the pharmacy label and the way the order was presented created inconsistencies in the documented volume, rate, and duration. The DON acknowledged that the nurse should have clarified the discrepancies with the pharmacy and followed up with the physician. The DON also confirmed that the TPN label indicated infusion at 125 ml/hr with a total volume and duration that did not mathematically align, and that there was confusion with the order as written. Despite these documented inconsistencies and the presence of an IV pump in the room, the TPN was administered via gravity drip and infused in a fraction of the intended time, leading to a substantiated medication administration error and associated change in the resident’s condition.
Failure to Manage PRN Morphine Orders Safely Resulting in Opiate Toxicity
Penalty
Summary
The deficiency involves the facility’s failure to provide pain management in accordance with professional standards of practice for a resident receiving morphine, resulting in opiate toxicity and hospitalization. The resident was admitted with sepsis, obstructive and reflux uropathy, and kidney stones, and had an existing order for immediate-release morphine 7.5 mg every 6 hours as needed for dorsalgia. On admission, medication reconciliation was completed with the family and primary care physician records. Shortly after admission, the resident complained of ongoing pain and requested more morphine than he was receiving. On 1/3, nursing documentation reflected instructions to give 0.5 tablet by mouth every 3 hours for pain and 1 tablet by mouth every 3 hours as needed for pain, and physician orders were entered for morphine sulfate 15 mg, both 0.5 tablet every 3 hours PRN and 1 tablet every 3 hours PRN, creating two active PRN orders for the same opioid at different doses and the same frequency. The new morphine orders significantly increased the potential daily morphine exposure. Based on the prescribed frequency and dosage, there was a potential for up to 180 mg of morphine to be administered in a 24-hour period, representing an increase of 150 mg per 24 hours from the prior regimen. On 1/5, the physician documented that the resident’s family reported slurred speech, and the physician assessed that there was intermittent dysarthria likely caused by morphine and stated that the morphine should be reduced unless needed for pain levels higher than 4; however, no updated morphine order reflecting this change was found in the medical record. Subsequent nursing notes documented clinical changes, including lethargy, slurred or unclear speech, low oxygen saturations, cough, shortness of breath, and the need for supplemental oxygen and nebulizer treatments. Despite these changes and the physician’s concern about morphine-related dysarthria, the dual PRN morphine orders remained, and there was no documented clarification or consolidation of the opioid orders. In the days leading up to the resident’s transfer to the hospital, the MAR showed administration of 15 mg morphine tablets with pain scores of 10, 7, and 4, totaling 45 mg in a 24-hour period. On the morning of transfer, nursing documented that the resident appeared lethargic, had cold extremities, and that oxygen saturation could not be obtained despite oxygen being titrated up to 5 L/min, with staff reporting a significant decline compared to the prior day. The resident was transferred to the ED for further evaluation. In the ED, the provider documented that the resident arrived critically ill with hypoxia, slow respiratory rate, confusion, and minimal responsiveness, and noted that the resident had been receiving extra doses above the 0.5 tablet of morphine he was supposed to be getting at least once or twice a day. The ED provider diagnosed opiate toxicity along with hypoxia and sepsis, and the resident responded to naloxone with improvement in respiratory rate, oxygenation, and blood pressure. Interviews with an LPN and the DON revealed that nurses relied heavily on resident request and subjective pain reports to administer morphine, did not consistently question high-frequency opioid orders, and did not obtain provider clarification when two different PRN orders for the same opioid existed, contributing to the unsafe pain management that led to opiate toxicity. Interviews further clarified the facility’s practices and expectations around opioid administration and order management. The LPN stated that when receiving a physician order, he would repeat it back and then enter it into the record, and that he typically would follow up with a provider if he encountered a morphine order more frequent than every 4–6 hours. However, in this case, he did not follow up with the provider regarding the every-3-hour morphine orders because the resident had been on morphine for some time and appeared to be tolerating it. He also stated that he administered morphine based on resident request, even when pain levels were low, and that on the day of the resident’s decline he gave the higher dose at the resident’s request despite lethargy. The DON stated she expected nurses to use nursing judgment and to contact the physician when there were two different orders for the same opioid, and acknowledged that the morphine order should have been written as a range (0.5 to 1 tablet every 3 hours). The combination of unclarified duplicate PRN morphine orders, lack of documented adjustment after the physician’s concern about morphine-related dysarthria, and reliance on resident preference without adequate clinical reassessment or provider consultation led to excessive morphine dosing and the resident’s opiate toxicity.
Failure to Investigate Serious Injury Incidents
Penalty
Summary
The facility failed to thoroughly investigate two reported incidents of potential abuse, neglect, exploitation, or mistreatment involving sampled residents. For one resident, the facility reported to the State Survey Agency that the resident had an unwitnessed fall during the night, initially resulting in mild left hip pain, followed by subsequent weakness in the left leg. A left knee X-ray obtained several days later showed a fracture of the distal femoral metaphasis, yet the Administrator confirmed there was no investigation documentation for this incident. For another resident, the facility reported that the resident sustained a head injury during a hoyer lift transfer, and a change in neurological status was identified the following day. A head CT scan revealed a subdural hematoma, but the Administrator in Training stated he could not locate the five-day summary report or any investigation of the incident. He acknowledged that investigations into these incidents should have been completed to rule out neglect or abuse.
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.
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