Citations in Washington
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Washington.
Statistics for Washington (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Washington
The facility did not ensure that meals were palatable, visually appealing, or served at appropriate temperatures, as reported by several residents and confirmed by surveyor observations. Residents described the food as bland, repetitive, and unappetizing, with some supplementing their diets with outside food or modifying their meals to improve taste. A test tray review found food items to be unappealing in appearance, taste, and temperature, and the Food and Nutrition Service Manager cited budget limitations as a factor.
The facility did not provide required written transfer or discharge notices to four residents or their representatives, and failed to document that a report was given to the receiving hospital for two residents. Staff confirmed that notices were sent to the LTCO but not directly to residents, and that communication with hospitals was not properly documented.
Staff failed to maintain a clean environment and adhere to infection control protocols, including not addressing a leaking catheter bag, not reporting a damaged mattress cover, and not following PPE and enhanced barrier precautions during high-contact care and suctioning procedures for multiple residents.
The facility failed to provide respiratory care and oxygen therapy according to physician orders and professional standards for four residents. This included administering oxygen without a provider order, not following prescribed flow rates, using oral suction equipment for stoma care, and not maintaining or replacing soiled oxygen equipment. Staff were unaware of proper procedures for equipment cleaning and did not consistently follow facility policy or update care plans to reflect accurate orders.
The facility did not have a system to assess or document the competencies of nurses and CNAs, resulting in staff providing care without evidence of proper training or skills assessment. For example, a nurse administered cancer therapy and performed stoma suctioning for a resident with complex needs without documented training or knowledge of required techniques. Staff files lacked competency records, and staff development processes did not ensure completion or collection of orientation and skills checklists.
A resident experienced a sustained decline in functional abilities, mood, and care acceptance following a hospitalization, but staff did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews and record reviews confirmed that the resident's condition had changed significantly, yet the necessary reassessment was not performed after the 14-day period.
A resident with complex medical needs and a history of falls was transferred using a slide board by two CNAs who were not trained or cleared to use this method, contrary to the care plan that required a mechanical lift except during therapy sessions. The resident began to slide during the transfer and was assisted to the floor. Staff interviews confirmed that only therapy staff were authorized to use the slide board, and nursing staff had not received the necessary training.
The facility did not ensure timely and accurate completion or updating of PASRR assessments for three residents with mental health diagnoses. One resident's required Level 2 referral was delayed by several months, another resident's follow-up with the State PASRR office was not documented, and a third resident's PASRR was not updated after new mental health diagnoses and medications were added.
A resident who was continent upon admission was managed solely with incontinence briefs without being assessed for bowel and bladder needs or offered a toileting program. Staff did not conduct formal assessments or implement a toileting plan, and the resident reported discomfort from the briefs and a willingness to try alternative continence care. The facility lacked a policy and process for bowel and bladder assessments, relying only on care plans focused on incontinence management.
The facility did not hold quarterly care conferences for two residents, resulting in missed opportunities to address care needs and concerns. One resident had not had a care conference since March, with no further attempts documented after a refusal in May. Another resident missed a scheduled conference since February and reported unaddressed concerns about food, emergency contacts, and mental health, with staff unaware of these issues.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that meals were prepared and served in a manner that maintained palatability, attractiveness, and safe, appetizing temperatures for six of nine residents reviewed. Multiple residents reported dissatisfaction with the food, describing it as unpalatable, repetitive, bland, and visually unappealing. Observations confirmed that residents were supplementing their diets with outside food, and some were seen attempting to modify their meals to improve taste. Specific complaints included mushy vegetables, unidentifiable dishes, lack of condiments, and food that was often turned away. Residents also noted that the menu was repetitive and that alternative options were not satisfactory. A test tray observation further substantiated these concerns, revealing food items that were visually unappealing, served at improper temperatures, and described as unappetizing by surveyors. The roast turkey had an unappealing color and was overly salty, the green beans had an unpleasant aftertaste, the bread dressing was gelatinous and unidentifiable, and the milk and dessert were served at temperatures that made them unpalatable. The Food and Nutrition Service Manager acknowledged the use of a long-standing menu cycle and indicated that budget constraints affected ingredient quality. These findings were based on resident interviews, direct meal observations, and review of facility policies.
Failure to Provide Required Transfer/Discharge Notices and Hospital Reports
Penalty
Summary
The facility failed to provide required written notices to residents and/or their representatives at the time of transfer or discharge for four residents, and did not ensure that a report was given to the receiving hospital for two residents. In several cases, staff completed the Nursing Home Transfer or Discharge Notice and sent it to the Long Term Care Ombudsman (LTCO) office, but did not provide the notice directly to the resident or their representative as required. Staff interviews confirmed that the notices were not given to residents unless they were being discharged to the community, and that notifications to the LTCO were sent in batches rather than at the time of transfer. Additionally, for two residents who were transferred to the hospital, there was no documentation that a report on the resident's condition was provided to the receiving hospital. Facility forms intended to document this communication were left blank, and staff acknowledged that it was their expectation for such reports to be given and documented, but this was not done. These failures were identified through interviews and record reviews, and were not in accordance with facility policy or regulatory requirements.
Failure to Maintain Infection Control and Adhere to PPE Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed deficiencies. For two residents, the environment was not kept clean to prevent the transmission of communicable diseases. One resident with a urinary catheter was observed with a leaking catheter bag, resulting in a puddle of urine on the floor beneath the bed. Staff interviews confirmed that both nurses and aides were expected to address such issues promptly, but the leak was not managed in a timely manner. Additionally, a resident's mattress cover was found to be missing a large piece, making it impossible to disinfect the mattress. Staff acknowledged that such issues should be reported to maintenance, but the problem was not logged as required. The facility also failed to follow proper use of personal protective equipment (PPE) and enhanced barrier precautions (EBP) for residents on transmission-based precautions. One resident with a history of multidrug-resistant bacteria had EBP signage posted, but a certified nursing assistant provided high-contact care without wearing a gown as required. Another resident requiring stoma care was attended to by a registered nurse who wore a gown, gloves, and mask, but failed to use eye protection during suctioning, despite knowing it was expected per facility policy. These lapses in following standard and enhanced precautions were confirmed through staff interviews and direct observation.
Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, resulting in care and services that were not consistent with professional standards of practice. For one resident with a stoma, staff did not implement suctioning according to physician orders and used oral suction equipment for stoma suctioning, contrary to expectations and without clarifying the method or route with the provider. Additionally, this resident received oxygen therapy without a physician order, and staff did not update the care plan to reflect accurate physician orders. Two other residents receiving oxygen therapy did not have their oxygen delivered at the physician-ordered flow rates. One resident's oxygen was set below the prescribed rate, and the nasal cannula was visibly soiled with debris, while the oxygen concentrator filter was covered in dust. Staff were unaware of the need to clean the filter and only replaced tubing when requested by the resident. Another resident was observed receiving oxygen at a higher flow rate than ordered, and the humidifier water bottle attached to the oxygen concentrator was empty on multiple occasions, despite orders to replace it as needed. A fourth resident was observed with a visibly soiled nasal cannula that had not been changed for an extended period, and the oxygen concentrator filter was covered in debris. Staff confirmed the tubing was dirty and needed to be changed, and the filter required cleaning. Across these cases, staff did not consistently follow physician orders, facility policy, or professional standards regarding respiratory care, oxygen administration, and equipment maintenance.
Failure to Assess and Document Nursing Staff Competencies
Penalty
Summary
The facility failed to develop and implement a system to evaluate and document staff competencies in essential nursing skills and techniques for all reviewed staff, including RNs and CNAs. There was no nursing competency policy available, and staff files lacked documentation of completed competency assessments. For example, a registered nurse administered a toxic cancer therapy medication and performed stoma suctioning for a resident with complex medical needs without having received specific training or instructions for these procedures. The nurse was unaware of the differences between oral and stoma suctioning techniques and had not received documented training on handling toxic cancer treatments. Multiple CNAs and nurses had no documented evidence of competency assessments or training in key care areas, such as safe resident transfers. Staff development personnel reported that orientation checklists were not collected, skills workshops for new hires were not yet offered, and the last documented skills workshop was held over a year prior, with no individual competency records available. The last completed staff competency checklists dated back to February 2023. Leadership staff confirmed that competency assessments were expected on hire and annually, but could not provide documentation to support that these assessments had occurred.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to reassess a resident following a significant and sustained decline in their functional and mood status after a hospitalization. The resident, who previously was able to get out of bed and go outside, reported that after returning from the hospital, they could no longer get out of bed. Observations confirmed the resident remained in bed, and record review showed a marked decline in their ability to perform activities such as upper body dressing and moving in bed, as well as changes in mood and care rejection behaviors. The most recent Minimum Data Set (MDS) assessment after the resident's return indicated total dependence in several areas and new instances of care rejection, compared to the previous MDS assessment before hospitalization, which showed greater independence and no care rejection. Despite these sustained declines in multiple care areas, the facility did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews with the Director of Nursing and the Corporate MDS Consultant confirmed that the changes in the resident's condition met the criteria for a SCSA, but the assessment was not performed after the 14-day period following the change. This omission was identified through interview and record review, and it was noted that the failure to complete the SCSA could result in unmet care needs and diminished quality of life for the resident.
Failure to Follow Care Plan and Provide Adequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision and follow established care plan interventions to prevent avoidable accidents for a resident with a history of falls and complex medical needs. The resident, who required substantial assistance for bed mobility and was dependent on staff for transfers, was observed to have experienced a fall during a transfer from chair to bed. The care plan specified that the resident was to be transferred using a mechanical lift, except when working with therapy, which was trialing slide board transfers. However, nursing staff used a slide board for the transfer without proper training or clearance from therapy, contrary to the care plan instructions. Multiple staff interviews confirmed that the resident was typically transferred with a mechanical lift and that only therapy staff were authorized and trained to use the slide board with the resident. On the day of the incident, two CNAs used a slide board for the transfer after being told by the resident and another CNA that this was now the method used, despite not being trained or cleared for this technique. The resident began to slide during the transfer and was assisted to the floor. The Director of Therapy confirmed that nursing staff had not been trained or cleared to use the slide board for this resident, and the Director of Nursing stated that staff are expected to follow care plan interventions and be adequately trained to reduce the risk of accidents.
Failure to Complete and Update PASRR Assessments for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed and updated for residents with mental disorders or intellectual disabilities. For three residents reviewed, there were significant lapses in the PASRR process. One resident with diagnoses of depression and anxiety had a Level 1 PASRR screening indicating the need for a Level 2 referral due to serious mental illness (SMI), but the referral was not made until seven months after the initial assessment. Another resident with anxiety and a mood disorder, who was prescribed antipsychotic medication, had a Level 1 PASRR submitted, but there was no documentation of follow-up with the State PASRR office or evidence of obtaining Level 2 services. For a third resident, hospital staff identified SMI indicators on the Level 1 PASRR, but did not specify the type of SMI, and a subsequent Level 2 evaluation determined no SMI based on hospital records. However, the resident was later prescribed antidepressant medication for an anxiety disorder, and the diagnosis was added to their records without an updated Level 1 PASRR being completed. Staff interviews confirmed that PASRRs were not updated in a timely manner when residents' mental health diagnoses changed or when new medications were prescribed. The facility's policy required timely validation and submission of Level 1 and Level 2 PASRRs, especially with significant changes in residents' mental health status, but these procedures were not followed for the residents in question. Documentation and communication with the State PASRR office were also lacking, resulting in incomplete or delayed assessments and referrals.
Failure to Assess and Address Bowel and Bladder Continence Needs
Penalty
Summary
The facility failed to assess and provide necessary care and services to maintain or improve bowel and bladder continence for a resident who was always incontinent of bowel and bladder. Despite documentation showing the resident was continent of bowel and had regular urinary frequency upon admission, subsequent quarterly reviews indicated no changes in bowel and bladder status, and the resident was consistently managed with incontinence briefs. Staff interviews revealed that the resident was never tried on a toileting program, and there was no evidence of a bowel and bladder assessment or toileting plan in the resident's records. The resident reported discomfort and difficulty sleeping due to the use of incontinence briefs and expressed willingness to try a toileting plan when asked. The facility was unable to provide a policy regarding bowel and bladder assessments when requested, and staff confirmed that no such assessment process was in place. The care plan interventions focused on managing incontinence with adult incontinence products rather than attempting to maintain or restore continence. Staff relied on the care plan to review bowel and bladder status but did not conduct formal assessments or implement toileting programs, even when the resident indicated awareness of the need to use the bathroom and a willingness to participate in a toileting plan.
Failure to Conduct Required Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences for two residents as required. For one resident, records showed the last care conference occurred in March, and although the resident refused a conference in May, there was no documentation of further attempts or scheduling of subsequent conferences. The resident reported that no one at the facility had discussed their care with them recently. Staff confirmed that no upcoming care conferences were scheduled for this resident, despite acknowledging the importance of these meetings for care planning and communication. For another resident, the last care conference was held in February, and the social services team missed scheduling the required quarterly conference. This resident expressed concerns about food, emergency contact information, and a desire to speak with a mental health specialist, but reported that staff did not discuss these issues with them. Staff were unaware of the resident's mental health concerns and confirmed that no mental health providers were following the resident for anxiety or panic behaviors, despite the care plan indicating such discussions should occur.
Some of the Latest Corrective Actions taken by Facilities in Washington
- Educated all staff on abuse-prevention policies and procedures to reinforce resident-rights protections (L - F0600 - WA)
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify, report, protect, assess, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with severe cognitive impairment and a history of aggressive behaviors. Staff documented multiple incidents where this resident engaged in hitting, punching, kicking, grabbing, scratching, yelling, and making threats toward other residents. Despite these repeated altercations, the facility did not consistently recognize these events as abuse, nor did they analyze the circumstances or implement effective interventions to prevent recurrence. The facility's own policies required staff to observe, assess, care plan, and monitor residents exhibiting behaviors that could lead to conflict, but these measures were not adequately followed. The resident in question had a documented history of severe cognitive impairment, dementia, and worsening verbal and physical behaviors that interfered with care and placed others at risk. Over several months, this resident was involved in at least 11 documented altercations with 10 different peers, including incidents of physical aggression such as hitting with objects, grabbing, scratching, and verbal abuse. Nursing progress notes and incident logs revealed additional unreported or inadequately investigated incidents, with some resulting in physical injuries to other residents, such as skin tears and scratches. Staff interviews confirmed that the resident's behaviors were unpredictable and escalated quickly, often resulting in fear and distress among other residents. Despite the frequency and severity of these incidents, the facility did not consistently treat verbal altercations as potential abuse unless threats were involved, and physical altercations were not always thoroughly investigated or reported. The care plan interventions implemented, such as 15-minute safety checks and behavioral monitoring, were insufficient to prevent further incidents. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, as required by policy and regulation.
Removal Plan
- Reviewed Resident 19's medications
- Placed Resident 19 on one to one supervision until lower level of care was determined to be appropriate
- Educated all staff to the abuse prevention policies and procedures
- Interviewed all residents to determine feeling safe and secure in the facility
Failure to Maintain Financial Obligations Resulting in Disruption of Essential Resident Services
Penalty
Summary
Facility administration failed to maintain effective financial management, resulting in overdue payments to multiple vendors, including laboratory services, utilities, staffing agencies, and medical supply companies. The administration was aware of the outstanding balances and received multiple demand notices and service discontinuation warnings from vendors. Despite this awareness, the facility did not ensure timely payment, leading to a disruption in essential services. On a specific date, the laboratory services provider placed the facility on a non-payment hold, which resulted in the discontinuation of laboratory services. As a direct consequence, four residents did not receive critical laboratory tests as ordered. These included Depakote levels for two residents, which are necessary to monitor therapeutic drug levels and prevent toxicity, a Comprehensive Metabolic Panel and Complete Blood Count for another resident, and a Hemoglobin A1C test for a fourth resident. Staff interviews confirmed that the missed laboratory services were due to the vendor not coming to the facility because of unpaid bills, and there was no alternative laboratory available for these tests. Additionally, staff reported that the facility had experienced a delayed payroll, resulting in a temporary loss of staff benefits and out-of-pocket expenses for medical needs. The business office manager and administrator both indicated that invoices were forwarded to the corporate office for payment, but payments were not made in a timely manner. The failure to pay vendors on time directly impacted the facility's ability to provide necessary care and services to all residents, as evidenced by the missed laboratory tests and the risk of further service interruptions.
Removal Plan
- Ensured resident lab testing had been completed.
- Ensured an active laboratory services vendor was in place.
- Provided evidence of vendor contract payments to ensure continuity of essential services.
- Audited resident laboratory orders.
- Obtained ordered laboratory testing for affected residents.
Failure to Assess and Supervise Resident Smoking, Leading to Immediate Jeopardy
Penalty
Summary
The facility failed to consistently and accurately assess residents' smoking abilities and implement safety interventions to prevent smoking-related injuries for three residents. Despite having a policy that prohibited smoking on facility grounds and required staff to secure smoking materials found with residents, the facility did not ensure that these procedures were followed. Staff were often unaware of which residents smoked, and there was a lack of clear documentation and care planning regarding residents' smoking status, supervision needs, and the storage of smoking materials. One resident with Parkinson's disease and diabetes was observed smoking unsupervised in the facility's patio area, near a propane tank, and without access to proper safety equipment such as ashtrays or fire blankets. This resident had a history of fluctuating consciousness and required assistance with mobility, yet was able to keep cigarettes and a lighter in their possession and smoke multiple times a day. The care plan for this resident did not include specific interventions to address their inability to manage smoking supplies safely, nor did it document where smoking materials were kept. Additionally, although a nicotine patch was recommended as part of a smoking cessation plan, it was not provided as indicated. Another resident with COPD and a history of tobacco abuse continued to smoke on facility property and in their room, even after being educated about the non-smoking policy and offered nicotine patches, which they refused. This resident set off the fire alarm by smoking in their bathroom and repeatedly refused to relinquish smoking materials, resulting in the need for increased supervision. A third resident with severe cognitive impairment had a history of daily smoking, but the facility's assessment failed to identify their tobacco use, and staff did not discuss smoking or the facility's policy with them. These failures led to unsafe conditions and represented an immediate jeopardy to resident health and safety.
Removal Plan
- Placed Resident 73 on one-to-one surveillance.
- Secured Resident 73's smoking paraphernalia.
- Re-assessed Resident 73's ability to smoke.
- Revised Resident 73's care plan to show the level of assistance and supervision required to smoke safely.
- Closed access to unsupervised patio areas.
- Added a fire blanket and an outdoor ashtray to the designated smoking area.
- Interviewed other residents and staff to identify other residents who smoked.
- Completed smoking safety evaluations of all residents in the facility and for any residents identified as a smoker/tobacco user.
- Developed or revised care plans for residents identified as smokers/tobacco users to show individualized interventions and supervision levels related to smoking preference.
- Completed a facility-wide sweep to remove unauthorized smoking materials.
- Notified residents of the smoking policy.
- Educated staff on the smoking policy, and identifying, managing, and reporting unsafe smoking behaviors.
Failure to Prevent Repeated Falls and Injuries Due to Ineffective Supervision and Intervention
Penalty
Summary
The facility failed to provide effective monitoring, supervision, and implementation of interventions to prevent repeated falls and injuries for multiple residents. For one resident with severe cognitive impairment and a history of falls, there were at least 15 documented falls, some resulting in serious injuries such as a dislocated hip, femur fracture, and back fracture. The facility did not consistently review or revise care plan interventions after each fall, and there were omissions in required neurological checks and documentation. Staff education on fall prevention was not always documented, and some falls were not included in the facility’s incident log. Another resident with dementia, impaired vision, and a history of frequent falls experienced 36 falls over a period of time, resulting in various injuries including abrasions, contusions, lacerations, and head injuries, with several hospital transfers. The care plan interventions remained largely unchanged despite repeated falls, and the facility continued to rely on ineffective strategies such as reminders to use the call light, even though the resident was impulsive and forgetful. There was no evidence that the facility evaluated the reasons for failed interventions or increased supervision, and staff interviews confirmed that increased monitoring was not attempted despite ongoing falls. A third resident, dependent on staff for transfers due to left-sided weakness from a stroke, fell while left unattended on the toilet, resulting in a fracture to the eye socket and left lower leg. The care plan had instructed staff to stay with the resident during toileting, but this intervention was not followed. The facility’s investigation acknowledged that staff left the resident unattended despite existing care plan instructions. Across these cases, the facility failed to assess, evaluate, and implement effective interventions to prevent repeated falls and injuries, and did not ensure that staff consistently followed care plan instructions or documented required assessments.
Removal Plan
- Placed both Resident 19 and 50 on one to one (1:1) supervision.
- Educated all staff to the policies and procedures for accident prevention and fall interventions, including notification to management of ineffective fall interventions.
- Reviewed accidents to ensure care planned interventions were resident specific.
- Reviewed Resident 19 and 50's care plans and ensured interventions were pertinent to the root-cause of the falls.
Unsafe Hot Water Access and Inadequate Supervision Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe water temperatures and adequate supervision to prevent accidents, resulting in serious harm to two residents. One resident, who had hemiplegia and cognitive impairment, was provided with hot water directly from a nurse's lounge auxiliary spout, which was measured at temperatures significantly above the safe limit of 120°F. The resident attempted to drink the water, spilled it on themselves, and sustained second-degree burns to the neck, chest, and abdomen. Staff interviews revealed that the hot water was routinely provided to this resident without checking or mixing the temperature, and staff were unaware of the actual temperature or the policy requirements. Another resident, with Alzheimer's disease and cognitive impairment, was observed entering the nurse's lounge unsupervised and accessing the same hot water auxiliary spout. This resident filled a metal container with hot water and resisted staff attempts to intervene, leaving the lounge with the hot water. Staff acknowledged that this resident had a history of entering nourishment areas to obtain hot water or use the microwave, often without supervision, and that residents were not permitted in the nurse's lounge. However, staff did not consistently prevent access or monitor the water temperature. Record reviews and staff interviews confirmed that the facility's policy required hot liquids to be served at safe temperatures, with water provided by dietary staff and not exceeding 120°F. Despite this, staff frequently used the nurse's lounge hot water spout, did not log or check temperatures, and were unaware of the risks. The lack of supervision and failure to adhere to safety protocols directly led to one resident's injury and placed another at risk of harm.
Removal Plan
- Remove the hot water auxiliary spout in the nurse's lounge
- Lock door to the nurse's lounge and require key access to nourishment rooms
- Provide training to staff
- Complete hot liquids evaluations for all residents
- Revise hot liquids safety policy
Failure to Assess, Notify Physician, and Ensure CPR-Certified Staff Leads to Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide a thorough assessment and timely recognition of a significant change in condition for a resident with a history of congestive heart failure and cellulitis. The resident experienced a rapid weight gain of 18.7 pounds in 24 hours, swelling in the left arm, slurred speech, difficulty breathing, and changes in mentation throughout the day. Despite these symptoms, there was no documentation that the physician was notified of the significant weight gain or the resident's deteriorating condition, as required by the care plan and physician orders. Multiple nursing assistants observed and reported the resident's changes, including incoherence, slurred speech, and abnormal appearance, to the assigned RN. However, the RN did not assess the resident in a timely manner, did not notify the physician, and did not document appropriate interventions. The last recorded vital signs were taken in the morning, and the resident's condition continued to decline throughout the day. When the resident became unresponsive and pulseless, there was a delay in initiating emergency interventions, and the RN did not perform CPR, leaving it to the nursing assistants. Further review revealed that the RN and other staff members lacked current CPR certification, contrary to facility policy requiring all RNs and LPNs to maintain active certification. The facility's failure to ensure adequate assessment, timely physician notification, and the presence of properly certified staff contributed to the resident's unexpected death. The resident was a full code and was not expected to pass away, with plans to return home after rehabilitation.
Removal Plan
- Terminated the staff that failed to assess, treat and notify the physician of Resident 1 regarding their significant change in condition.
- Audited the records of all residents for unidentified changes in condition.
- Educated staff on what to do when a resident has a change in condition.
- Audited employee Cardiac Pulmonary Resuscitation (CPR) certifications to ensure there were an adequate number of staff working each shift with active CPR certifications.
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