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
Surveyors found that the facility did not promptly report or investigate multiple incidents of alleged abuse, neglect, elopement, and injuries of unknown origin involving residents with severe cognitive impairment. These included unreported sexual contact between cognitively impaired residents, several resident elopements—some resulting in injury, and a resident injury during transport. Staff and administration often failed to recognize or act on the need for immediate reporting to the State Survey Agency, as required by regulations.
Multiple residents with severe cognitive impairment were involved in repeated incidents of sexual contact and elopement without proper assessment of their capacity to consent or adequate supervision. Staff and administration failed to document capacity evaluations, relied on superficial signs of consent, and did not conduct thorough abuse investigations, resulting in unaddressed abuse and neglect.
Surveyors found that the facility did not thoroughly investigate or report multiple incidents involving abuse, neglect, elopement, and injuries of unknown origin. Several residents with severe cognitive impairment were involved in incidents of sexual contact, elopement, and unexplained injuries, but the facility failed to conduct formal investigations or notify the State Survey Agency as required. Staff and administration acknowledged that these events were not properly handled or documented.
Surveyors found that the facility did not have or implement adequate policies and procedures to prevent abuse, neglect, or theft, particularly regarding sexual abuse and elopement. Multiple residents with severe cognitive impairment were involved in incidents of sexual contact or attempted sexual contact without documented assessments of their capacity to consent or proper investigations. The facility failed to report or thoroughly investigate these incidents, and did not have written protocols defining sexual abuse or procedures for evaluating consent.
Multiple residents with cognitive impairment eloped from the facility, with some incidents requiring staff to intervene to prevent harm. Two residents experienced falls without subsequent updates to their care plans, and one resident was injured during transport due to improper wheelchair securement. Staff responses and documentation were inconsistent, and not all incidents were reported or investigated as required.
Three residents with complex medical and behavioral needs experienced multiple incidents, including falls, choking, and elopement, without timely updates to their care plans. Despite documentation of these events and staff discussions, care plans were not revised to include new interventions or reflect current needs, and some interventions remained outdated or inappropriate for the residents' conditions.
The facility did not provide staff with required training on abuse, neglect, exploitation, or misappropriation of resident property, nor on proper reporting procedures. Staff interviews and review of in-service records showed that education was inconsistent and did not cover key topics such as definitions of abuse, reporting protocols, or consent. The administrator confirmed that current training did not ensure staff understanding or compliance.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Two residents with cognitive impairment and complex medical histories experienced significant weight loss due to the facility's failure to provide necessary mealtime cueing, adaptive equipment, and consistent monitoring. Staff did not always follow care plan interventions, and there were gaps in documentation and understanding of snack and supplement intake, resulting in inadequate support for maintaining nutritional status.
The facility did not provide necessary behavioral health care and services to a resident, resulting in unmet behavioral health needs.
Failure to Timely Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to immediately report, within the required two-hour timeframe, multiple alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and elopement to the State Survey Agency. In several cases, incidents involving sexual contact between cognitively impaired residents were not reported or investigated, despite both residents having severe cognitive impairment as indicated by low BIMS and SLUMS scores. Staff and administration assumed the interactions were consensual, even though the residents' cognitive status called their ability to consent into question. Additionally, an incident involving a resident being found undressed with another resident, and another case where a resident was found in another's bed, were not reported or investigated as potential abuse or sexual assault. The facility also failed to report multiple incidents of resident elopement. Several residents with severe cognitive impairment and a history of wandering or elopement were able to leave the facility grounds unsupervised, sometimes by climbing or breaking through fences. In some cases, residents were found by staff or police outside the facility, and in one instance, a resident sustained a skin tear during an elopement. These incidents were not reported to the State Survey Agency as required, and in some cases, the administration was unaware of the reporting requirements for elopement events. Additional deficiencies included failure to report injuries of unknown origin and incidents during transportation. One resident with severe cognitive impairment was observed with a large bruise to the eye, and the cause could not be determined, but the incident was not reported for investigation. Another resident fell out of a wheelchair during transport due to improper securing, resulting in a head abrasion, and this incident was reported late. In all these cases, the facility did not follow required protocols for timely reporting and investigation of potential abuse, neglect, or injury, as confirmed by staff and administrative interviews and record reviews.
Failure to Protect Cognitively Impaired Residents from Abuse, Neglect, and Unassessed Sexual Contact
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, specifically failing to ensure that residents with severe cognitive impairment were free from sexual abuse and neglect. Several residents with diagnoses such as dementia, Alzheimer's disease, traumatic brain injury, and other cognitive disorders were involved in repeated incidents of sexual contact without documented assessments of their capacity to consent. In multiple cases, residents with severe cognitive impairment were found engaging in sexual acts or intimate behaviors with other residents, and staff determined these interactions to be consensual based on superficial observations, such as the absence of resistance or distress, rather than formal capacity assessments. There was no evidence in the medical records that any of the involved residents had been evaluated for their ability to consent to sexual activity, despite clear documentation of severe cognitive deficits and fluctuating mental status. The report details several specific incidents, including residents being found undressed together, engaging in sexual acts, or being discovered in each other's rooms. In one case, a resident with a BIMS score of 3 and a MOCA score of 7, both indicating severe cognitive impairment, was repeatedly found in intimate situations with other residents, some of whom also had severe cognitive impairment. Staff and administration often relied on the residents' apparent comfort or lack of protest to determine consent, even when family members and staff acknowledged the residents' confusion and inability to understand their circumstances. In another case, a resident with a traumatic brain injury and aphasia was found in a sexual situation with another cognitively impaired resident, and the facility failed to conduct or document an abuse investigation or implement effective safety measures to prevent recurrence. Additionally, the facility failed to prevent neglect in the form of elopement, as two residents were able to leave the facility and return without staff knowledge. The lack of supervision and failure to update or implement appropriate care plan interventions for residents at risk of elopement further contributed to the finding of neglect. The surveyors identified these failures as Immediate Jeopardy, citing the facility's lack of adherence to Centers for Medicare and Medicaid Services recommended practices to prevent abuse and neglect, and the absence of thorough investigations and documentation regarding incidents of sexual contact and elopement among cognitively impaired residents.
Failure to Investigate and Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate and report multiple allegations of abuse, neglect, and mistreatment involving several residents. Incidents included sexual contact between residents with severe cognitive impairment, elopements, injuries of unknown origin, and fractures. In several cases, residents with diagnoses such as dementia, psychotic disorders, and traumatic brain injuries were involved in situations where their ability to consent was questionable, yet no formal investigations were conducted. For example, one resident with a BIMS score indicating severe cognitive impairment was found in close proximity or engaging in physical contact with other residents on multiple occasions, but the facility did not document any investigation into these incidents. In another case, a resident was found with another resident in a compromising situation, and although staff separated them, no investigation was initiated, and the event was not reported to the State Survey Agency. The facility also failed to investigate and report multiple elopement incidents. Residents with significant cognitive impairment and a documented history of wandering or elopement risk were able to leave the facility premises on several occasions. In some instances, residents were found outside the facility or even on public streets, and staff had to intervene to bring them back. Despite these events, there was no evidence of a formal investigation or reporting to the State Survey Agency. Staff interviews confirmed that these incidents were not investigated or reported as required, and the administrator acknowledged that these events should have been handled differently. Additionally, the facility did not investigate injuries of unknown origin. For example, a resident with severe cognitive impairment was observed with a large bruise to her right eye, and although the incident was noted in the medical record, there was no documentation of an investigation to determine the cause. The DON stated that such injuries should be investigated and reported if the cause is unknown, but no investigation was provided. The administrator also confirmed that investigations were primarily informal and that some incidents were not reported due to a lack of clarity on reporting requirements.
Failure to Implement Abuse Prevention and Consent Assessment Policies
Penalty
Summary
Surveyors identified that the facility failed to implement and follow written policies and procedures to prevent abuse, neglect, and theft, specifically regarding sexual abuse, capacity to consent to sexual activity, and elopement. The facility did not have written definitions or protocols for evaluating a resident's capacity to consent to sexual relationships, nor did it have adequate procedures for investigating and reporting allegations of abuse. Multiple incidents involving residents with severe cognitive impairment engaging in sexual contact or being found in compromising situations were documented without evidence of proper assessment of their ability to consent or thorough investigation of the events. Several residents with diagnoses such as dementia, traumatic brain injury, and other cognitive disorders were involved in incidents of sexual contact or attempted sexual contact. For example, one resident with a BIMS score indicating severe cognitive impairment was found in multiple situations involving physical intimacy with other residents, none of whom had documented assessments of their capacity to consent. Another resident with a history of neurocognitive disorder and severe cognitive impairment was found in other residents' rooms and beds, sometimes with residents who were partially undressed or engaged in physical contact. In one case, a resident was found with her underwear down and another resident attempting to initiate sexual contact, but there was no documentation of an abuse investigation or capacity assessment. The facility's records showed repeated failures to document or conduct assessments for capacity to consent to sexual activity, despite clear evidence of cognitive impairment and repeated incidents. Incident reports and progress notes often described the events as consensual or inconclusive without supporting documentation or proper evaluation. In some cases, incidents were not reported to the State Survey Agency or law enforcement as required, and there was no evidence of timely or thorough investigation into allegations of abuse or neglect. These failures were cited at the Immediate Jeopardy level due to the facility's lack of effective policies and procedures to prevent and address abuse, neglect, and elopement.
Failure to Prevent Elopement, Falls, and Transport Injuries Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that residents received adequate supervision to prevent accidents, resulting in multiple incidents involving elopement, falls, and injuries. Three residents with cognitive impairment eloped from the facility, with two of these incidents reaching the level of immediate jeopardy. In one case, a resident with severe cognitive impairment and a history of elopement repeatedly escaped the facility by breaking through or climbing over fences, sometimes requiring staff intervention to prevent the resident from entering traffic. Documentation showed that staff were aware of the resident's behaviors, but interventions were limited to verbal redirection and monitoring, and not all incidents were reported or investigated as required. Another resident with vascular dementia and agitation also eloped on multiple occasions by climbing over fences, resulting in a skin tear during one incident. Despite these events, there was no evidence that the resident's elopements were investigated or reported to the state survey agency. Additionally, this resident experienced several falls, including incidents where the resident hit his head or was found on the floor, but the care plan was not updated to reflect new interventions after these falls. Staff interviews confirmed that interventions were not consistently added to the care plan following such incidents. A separate incident involved a resident who was not properly secured in a facility van during transport, resulting in the resident tipping backward in his wheelchair and sustaining a head abrasion. The staff member responsible for transport admitted to not securing the wheelchair correctly and stated that initial training was verbal and lacked demonstration. Documentation of training was incomplete, and the facility could not provide evidence that the staff member had been properly trained prior to the incident. Other residents were also found in unsafe positions, such as lying on the floor or between the bed and wall, without staff present or timely intervention.
Failure to Update and Implement Comprehensive Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulation. For each resident, the care plans did not include measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs as identified in their comprehensive assessments. Specifically, care plans were not updated following significant changes in condition or incidents, resulting in care plans that did not reflect the current needs or required services for the residents. One resident with vascular dementia, agitation, and a history of falls experienced multiple falls over several months. Despite documentation of these incidents in progress notes and incident reports, the resident's care plan was not updated after each fall to reflect new interventions or changes in care. Interviews with staff confirmed that interventions discussed in meetings and huddles were not consistently incorporated into the written care plan in a timely manner. Another resident with severe cognitive impairment, alcohol dependence, and a history of falls and choking incidents had multiple documented falls and a choking event. The care plan included outdated interventions, such as providing a bowl of nuts, which was not appropriate for the resident's current dietary needs. The care plan was not updated with new interventions after each incident, and staff interviews revealed a lack of awareness of the resident's current care needs. A third resident with severe cognitive impairment and exit-seeking behaviors had multiple documented elopements and attempts to leave the facility. Despite these incidents, the care plan was not updated with new approaches after each event, and staff interviews indicated uncertainty about who was responsible for updating care plans.
Failure to Provide Required Staff Training on Abuse, Neglect, and Reporting Procedures
Penalty
Summary
The facility failed to provide staff training that met minimum requirements for educating staff on abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and preventing abuse and neglect. Interviews with staff, including a nursing assistant and a registered nurse, revealed that while some education was provided, it was generally limited to addressing issues that needed correction and did not consistently cover the required topics. Staff were unclear about the content and purpose of Quality Assurance and Performance Improvement (QAPI) meetings, and there was no evidence that education on consent or comprehensive abuse prevention was included in the training. Review of in-service training records from January through July showed that none of the agendas included specific abuse training. While there were trainings on dementia, assault, de-escalation, and communication, these did not define abuse, explain its types, outline reporting procedures, or clarify who could give consent. The administrator acknowledged that the abuse training needed updating and that current education did not ensure staff understanding or practice of the required concepts.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.
Failure to Maintain Nutritional Status and Provide Adequate Mealtime Assistance
Penalty
Summary
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutritional parameters and provide necessary assistance during meals. One resident, with severe cognitive impairment and multiple comorbidities including Parkinson's disease and dementia, lost 14.4 pounds over six months without new interventions being implemented. Despite care plan interventions such as monitoring for malnutrition and providing adaptive equipment, the resident was not observed using specialized dinnerware and continued to lose weight even while documented as consuming 76-100% of meals on most days. Staff interviews revealed inconsistent understanding of the resident's needs, and the resident was not always cued to eat as required. Another resident, with diagnoses including Alzheimer's disease, diabetes, and recent fractures, also experienced ongoing weight loss. Observations showed the resident frequently left the dining room without eating, required cueing to eat, and sometimes attempted to eat with inappropriate utensils. Although the care plan indicated the need for setup assistance and cueing, staff did not consistently provide this support, and meal intake documentation showed frequent low consumption or refusal of meals. Supplement and snack intake were also low, and there was confusion among staff regarding documentation and provision of snacks. Interviews with dietary and nursing staff highlighted gaps in communication and documentation regarding residents' nutritional intake, especially for snacks and supplemental feedings. The registered dietician acknowledged concerns about weight loss and was unsure where snack intakes were documented. The dietary manager and CNAs were unclear about procedures for residents who missed snacks or required additional assistance, contributing to the facility's failure to ensure adequate food and fluid intake to maintain residents' health.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents did not receive the behavioral health care and services necessary to address their individual needs, as required by regulations.
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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