Citations in Wisconsin
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wisconsin.
Statistics for Wisconsin (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Updated the smoking policy to specify locked storage locations for all smoking materials to reduce unsafe smoking hazards (K - F0689 - WI)
- Educated staff on smoking policies/procedures, elopement protocols, monitoring for exit-seeking behavior, and verification of WanderGuard placement/function (K - F0689 - WI)
- Initiated routine audits to confirm smoking materials remain secured and WanderGuards are in place and functional (K - F0689 - WI)
- Revised the elopement policy to include guidance for situations when a resident removes a WanderGuard device (K - F0689 - WI)
- Educated facility and agency staff on abuse-prevention and restraint-use policies (J - F0604 - WI)
- Implemented mandatory elopement training during every staff member’s first shift to ensure competency from day one (J - F0689 - WI)
- Established a tiered auditing system for resident rounding and safety checks, with DON/ADON oversight and QAPI review of results (J - F0689 - WI)
Failure to Prevent Accident Hazards: Unsafe Smoking and Elopement
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, resulting in deficiencies related to unsafe smoking practices and inadequate elopement prevention. One resident, who was cognitively intact and had a history of noncompliance with smoking policies, repeatedly smoked cigarettes in their room despite the facility's policy requiring smoking only in designated areas. The resident's care plan was not updated in response to multiple documented violations, and staff failed to revise the smoking assessment or implement additional safety interventions after incidents, including one where a hot cigarette butt singed trash in a shared bathroom. The resident's medical record also indicated a history of disruptive behavior and previous fire-related incidents in another facility, yet the facility did not adjust the care plan or restrict access to smoking materials accordingly. Another resident, with moderate cognitive impairment and a history of exit-seeking behavior, was not adequately supervised to prevent elopement. The resident's care plan required the use of a WanderGuard device and securing the window to prevent unsupervised exits. However, staff failed to ensure the WanderGuard was consistently in place and functioning, and the window in the resident's room was found to open fully, contrary to care plan instructions. The resident was observed without a WanderGuard on multiple occasions and was able to exit the building unsupervised through an emergency exit. Staff interviews revealed that the resident frequently removed the WanderGuard, and incidents of elopement were not documented or reported to administration as required. The facility's inaction in revising care plans, conducting new assessments, and ensuring the implementation of safety interventions for both residents led to a finding of immediate jeopardy. The lack of supervision and failure to enforce policies regarding smoking and elopement prevention created a situation where residents, including those with physical and cognitive limitations, were exposed to significant safety risks. Documentation and communication lapses further contributed to the ongoing deficiencies.
Removal Plan
- Remove smoking materials from R19's room and store them in a locked area.
- Reeducate R19 and have R19 sign the facility's smoking policy and behavior contract for smoking.
- Place R19 on checks to ensure smoking materials are not found in R19's room.
- Revise R19's care plan to reflect R19's current smoking plan.
- Update the facility's smoking policy to include information on where smoking materials will be kept to maintain safety and reduce the risk of unsafe smoking.
- Educate residents who smoke on the facility's smoking policy, review the designated smoking area, and collect all smoking materials for safe storage.
- Educate staff on the facility's smoking policy and procedure.
- Initiate audits to ensure all smoking materials remain locked and the smoking policy is being followed.
- Place a WanderGuard on R27 and review R27's order to ensure staff check placement, location, and function.
- Place R27 on checks to monitor R27's location and ensure safety.
- Secure the window in R27's room.
- Revise R27's care plan with updated interventions.
- Review residents at risk for elopement to ensure interventions are appropriate and in place.
- Educate staff on the facility's elopement policy and the importance of monitoring for exit seeking behavior.
- Educate staff on the importance of checking for WanderGuard placement and function.
- Review the facility's elopement policy to ensure information is included regarding what to do when a resident removes a WanderGuard.
- Initiate audits to ensure WanderGuards are in place and functioning properly.
Failure to Assess and Respond to Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a significant change in condition. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, polyneuropathy, hypotension, COPD, and sleep apnea, presented with symptoms including abdominal pain, nausea, distension, and changes in mental status. Despite these symptoms, staff did not document all of the resident's symptoms in the medical record, nor did they complete a thorough and ongoing RN assessment related to the change in condition. There were multiple instances where staff failed to perform a full set of vital signs, abdominal assessments, or pain assessments, even when the resident expressed severe discomfort and abnormal findings were present. The facility's own policy required prompt identification and effective action in response to changes in condition, including in-depth RN assessments and immediate notification of the attending practitioner. However, documentation shows that these steps were not consistently followed. For example, when the resident reported severe abdominal pain and other symptoms, staff administered medications but did not perform or document comprehensive assessments or notify the physician in a timely manner. Critical lab results indicating hyperkalemia and abnormal kidney function were not acted upon with the urgency required, and vital signs that warranted immediate physician notification were not communicated as per standard protocols. Additionally, there was a lack of ongoing monitoring and documentation of the resident's deteriorating condition. Interviews with facility leadership and staff confirmed that expected assessments and documentation were not completed, and that the medical record did not accurately reflect the resident's symptoms or the care provided. The failure to document and respond appropriately to the resident's change in condition, including not notifying the physician of critical changes and not providing continued monitoring, contributed to the resident's continued decline. The resident was eventually transferred to the hospital, where he was found to be pulseless and nonbreathing and subsequently expired due to a critical potassium level.
Removal Plan
- LPN R's employment was terminated.
- Vitals were taken on all residents to ensure no change in condition or need for additional assessment.
- Educational in-services on change in condition were provided for all clinical staff.
- Interviewed all residents and [NAME] of Attorney regarding comfort with cares and facility responsiveness to clinical needs to ensure the facility continues to meet the resident needs to their satisfaction.
- DON B performed chart review for all residents to ensure all changes in condition noted were accompanied by follow-up assessments and proper notification.
- DON B organized a skills fair for nursing to ensure competence in assessments, evaluations, nursing skills, and clinical judgement.
- Management team revamped morning meeting process with additional audits and accountability on 24 hour board.
- Continue audits and education on Stop and Watch program for entire staff. DON B will continue to provide scenarios.
Resident Physically Restrained by CNA Using Nightgown and Blanket
Penalty
Summary
A resident with Alzheimer's disease, hemiplegia, hemiparesis, major depressive disorder, and aphasia, who required total assistance for lower torso care and had a history of tearing apart incontinence briefs, was physically restrained by a Certified Nursing Assistant (CNA) during a PM shift. The CNA tied the sleeves of the resident's nightgown closed with the resident's arms inside and tucked a blanket across the resident's lap and under both sides of the mattress. This action was taken after the resident repeatedly attempted to remove their brief. As a result, the resident was unable to access their hands, move freely in bed, or reach the call light. The restraint was discovered by a Licensed Practical Nurse (LPN) during a routine check on the next shift, approximately two and a half hours later. The LPN found the resident with their arms inside the nightgown and a blanket tucked under the mattress, immediately untied the sleeves, and provided care. The resident was assessed for physical and psychological harm, with no new injuries noted, although bruising was observed on the tops of the resident's hands, which was determined not to be new. The resident, when interviewed, was only able to provide limited responses but indicated feeling fine and not having been hurt. Staff interviews and record reviews confirmed that the CNA had restrained the resident to prevent them from tearing at their brief and throwing items. The facility's policy prohibits the use of physical restraints for discipline or convenience and defines a physical restraint as any method that restricts freedom of movement or normal access to one's body. The CNA acknowledged in a statement that tying the sleeves was a poor decision, and the facility determined that the resident had been restrained during the last rounds of the PM shift.
Removal Plan
- Initiated physical and psychosocial monitoring for R1.
- Completed skin assessment for other cognitively impaired residents.
- Notified CNA-C's staffing agency and did not allow CNA-C to return to the facility.
- Educated facility and agency staff on the facility's abuse and restraint policies.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Three residents receiving intravenous (IV) antibiotics experienced significant medication errors due to failures in medication order clarification, unauthorized changes to physician orders, and missed doses. One resident was admitted with a complex medical history including osteomyelitis, bacteremia, and acute kidney injury, and had a hospital discharge order for IV cefepime. Staff did not recognize a dosing error in the discharge order and entered it incorrectly into the facility's system. Subsequently, a registered nurse changed the order without consulting a physician, resulting in discrepancies between the hospital discharge order, the facility physician's order, and the nurse's revised order. The resident missed three doses of IV antibiotics over four days, and there was no documentation that the physician was notified of these missed doses. Another resident with multiple chronic conditions, including pneumonia, MRSA infection, and diabetic foot ulcer, had a physician order for IV vancomycin. The medication administration record (MAR) showed that a scheduled dose was not administered, and there was no documentation that the physician was notified of the missed dose. Additionally, a change in the administration time was communicated to the infectious disease office, but subsequent missed doses were not reported to the physician. A third resident with diagnoses including bacteremia, osteomyelitis, and diabetes was prescribed IV ceftriaxone via a PICC line. The MAR indicated that a scheduled dose was not administered because the resident was away from the facility for a physician appointment. There was no documentation that the physician was notified of the missed dose, and the facility physician confirmed that they were not made aware of the missed administration. In all cases, the facility failed to ensure that IV antibiotics were administered as ordered and that physicians were notified when doses were missed.
Removal Plan
- Review R203's medication orders for accuracy and availability and notify Infectious Disease (ID) of missed doses.
- Audit all residents on antibiotics and verify their medications are available and being administered.
- Educate nursing staff on the facility's policy for administering medication per physician orders and what to do when medications are unavailable.
- Educate nursing staff on confirming pharmacy orders with the physician and that nurses may not change medication orders without physician approval.
- Initiate audits to ensure admission orders are transcribed correctly and have been received from the pharmacy.
Failure to Prevent Elopement and Inadequate Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for two residents, resulting in actual harm. One resident, with a history of elopement, dementia, mood disturbance, and protective placement by court order, repeatedly expressed a desire to leave the facility and had previously left medical appointments early or eloped. Despite these documented behaviors and a prior incident where the resident eloped from a hospital appointment, the facility did not implement a proactive elopement care plan or provide supervision during off-site appointments. The resident was again sent to a hospital appointment unaccompanied, where he eloped and was found at a hotel several hours later. Staff interviews revealed a lack of awareness of the resident's prior elopement history and no clear rationale for allowing the resident to attend appointments alone, despite known risks. Another resident, with diagnoses including repeated falls, cognitive impairment, and dependence on staff for mobility and self-care, was found outside the facility unattended for over an hour on a hot day. The resident was discovered by staff arriving for their shift, exhibiting signs of dehydration, heat exposure, and renal insufficiency, and required hospitalization. Prior to this incident, there was no protocol in place to monitor unsupervised residents who exited the building to go outdoors. Staff interviews indicated that residents considered independent were not routinely checked on when outside, and there was no clear system to track how long a resident had been outside or to ensure their safety while off the unit or building grounds. The facility's lack of proactive assessment, individualized care planning, and supervision for residents at risk for elopement or harm resulted in both residents experiencing actual harm. The absence of effective monitoring protocols and staff awareness contributed to the failure to prevent these incidents, as evidenced by the residents' ability to leave unsupervised and suffer adverse outcomes.
Removal Plan
- Affected resident continues to have periodic onsite checks in alignment with resident rounding policy.
- All Staff will be educated regarding elopement on their very first shift in their work unit.
- R2's care plan has been updated to require attendant at each external appointment/outing.
- Facility has made contact with the Guardian who is agreeable to a care plan meeting to discuss possible placement in the community, as this is what the member expressed a desire to do.
- Facility has reviewed court determined member rights restrictions and has updated R2's care plan to reflect any/all court order rights and/or removals.
- Member's care plan has been updated to include checks whether member is in the building or anywhere on the premises.
- Facility reviewed Member rounds policy and member elopement policy. The policies remain appropriate.
- DON, ADONs and or designated licensed staff will audit member rounding and safety checks on all residents. If no concerns noted, will perform audit every two weeks. If no concerns, will perform audits monthly. If no concerns, random audits will be done.
- All Audits will be reviewed during the facility's QAPI meetings.
- Facility will ensure attendant goes to every off-site appointment the member has, attendant will be identified in the appointment note in the EHR (Electronic Health Record).
Latest Citations in Wisconsin
A resident's allegation of abuse by a CNA was not documented as reported to the State Survey Agency within the required two-hour timeframe. The facility's incident report remained in draft status with missing submission details, and there was no verifiable evidence that the initial report was made promptly, as required by policy.
Thirteen residents experienced misappropriation of their trust funds when a staff member manipulated account transactions for personal gain. The staff member concealed unauthorized withdrawals, making them appear legitimate and bypassing existing oversight procedures. Despite the discrepancies, residents did not report issues accessing their funds, and no negative outcomes were reported during interviews.
Several residents experienced significant delays in receiving room tray meals, with breakfast and lunch often served 30 minutes to an hour past posted times. Residents expressed frustration over the wait, especially when compared to those eating in the dining room, and reported that concerns had been raised repeatedly in resident council meetings. Staff interviews revealed a lack of awareness about the extent of the issue, and observations confirmed that meal trays were left on carts for extended periods before delivery.
Surveyors observed multiple failures in infection prevention and control, including staff not performing hand hygiene between glove changes, not using required PPE during high-contact care for a resident on enhanced barrier precautions, and leaving a catheter drainage bag uncovered and on the floor. These lapses occurred during care for residents with significant medical needs, including wounds and catheters, and were confirmed by staff interviews and record review.
A resident with multiple cardiac and neurological conditions was returned to the facility with a cardiac monitor, but staff failed to assess the resident's ability to use the device, did not document monitoring or device checks, and did not obtain or follow up on necessary orders or instructions. Interviews confirmed a lack of documentation and follow-up regarding the cardiac monitor, resulting in a deficiency related to appropriate care and treatment.
Three residents with respiratory conditions used CPAP machines without timely physician orders for use, cleaning, or maintenance, as required by facility policy. Observations showed that some residents' CPAP equipment was visibly dirty, and residents reported not receiving needed staff assistance with cleaning. Staff acknowledged that orders and cleaning should have been completed upon admission, but these actions were not taken.
A resident was found with hydrocortisone cream at their bedside without a physician's order or authorization for self-administration. Facility policy requires an order and assessment for bedside medication, but neither was present in the medical record. Staff confirmed the absence of an order and that the medication was not on the MAR, resulting in a failure to ensure safe and accurate drug administration.
A resident who was cognitively intact and had prepaid for nursing care was discharged before the end of the paid period, but the facility failed to issue a refund within the required 30 days. The refund was delayed due to issues with the accounts payable system, and was not processed until more than two months after discharge, despite multiple follow-ups by the resident's family.
A resident with diabetes and a recent hospital stay did not receive prednisone according to the prescribed tapering schedule due to transcription errors in the EMR, resulting in missed and incorrect doses. Additionally, staff failed to notify the provider of two blood glucose readings over 400 mg/dL, with no documentation of provider notification or additional interventions, despite facility policy requiring such actions.
Two residents with newly identified or existing pressure injuries did not receive timely wound treatment orders. In both cases, wounds were identified and noted in documentation, but treatment orders were either not entered into the EMR or were delayed for an extended period. Facility policy required prompt assessment and provider notification, but these steps were not consistently followed, resulting in a lack of timely wound care.
Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to provide evidence that an initial report of an abuse allegation was submitted to the State Survey Agency (SA) within the required two-hour timeframe for one of two residents reviewed for abuse. According to the facility's policy, all alleged violations involving abuse or serious bodily harm must be reported immediately, but not later than two hours after discovery. In this case, a resident alleged that a Certified Nurse Aide (CNA) refused to assist her to bed and was mean to her. The facility's documentation included a printed Misconduct Incident Report with the incident details, but the report was marked as a draft, and critical sections such as "Report Submitted BY" and "Report Submitted Date" were left blank. There was no documentation to confirm the actual date and time the report was submitted to the SA. During interviews, the Administrator referenced the Incident ID on the report as evidence of submission, but the absence of a submission date and time meant there was no verifiable proof that the abuse allegation was reported within the required two-hour window. The lack of proper documentation and timely reporting had the potential to delay corrective measures and appropriate responses to the abuse allegation, as required by facility policy and regulatory standards.
Misappropriation of Resident Trust Funds by Staff Member
Penalty
Summary
The facility failed to protect the belongings and funds of thirteen residents, resulting in misappropriation of resident trust funds by a former Business Office Manager (FBOM). The FBOM was found to have taken monies from the resident trust for personal gain, with discrepancies identified in the accounts of multiple residents. The incident was discovered after suspicions arose regarding unauthorized use of the facility credit card, prompting an internal investigation and audit of the resident trust fund, facility credit card, and petty cash accounts. The audit revealed that the FBOM had manipulated transactions to appear legitimate, making the misappropriation difficult to detect. Interviews with facility leadership confirmed that the FBOM had a clean background check and no prior indications of misconduct. The FBOM was able to conceal the movement of funds and falsify documentation, which allowed the misappropriation to go unnoticed during routine oversight. Despite the discrepancies, residents did not report issues with accessing their funds when requested, and no negative outcomes were voiced by residents during interviews conducted as part of the survey process. A review of facility policies indicated that procedures were in place to safeguard resident funds, including requirements for documentation, witness signatures for disbursements, and monthly transaction reviews. However, these controls were insufficient to prevent the FBOM from accessing and misappropriating resident funds. The deficiency was identified through the facility's own investigation and subsequent audit, which flagged irregularities in the trust accounts of thirteen residents.
Delayed Meal Service for Room Trays
Penalty
Summary
The facility failed to ensure that meals and snacks were served at regular times and according to resident preferences for seven sampled residents. Multiple observations over several days revealed that room trays for breakfast and lunch were consistently delivered 30 minutes to an hour after the posted meal times. Residents reported frequent delays, with some indicating that breakfast was sometimes not served until nearly two hours after the scheduled time. Residents who received room trays expressed frustration at having to wait significantly longer than those who ate in the dining room, and several noted that the issue was ongoing and had been discussed in resident council meetings. Surveyors observed that room trays were plated first but then left on carts for extended periods before being delivered to residents' rooms. The delivery process involved multiple stops across different units, further delaying meal service. Residents interviewed described feeling upset and dissatisfied with the wait times, particularly for breakfast and lunch. Some residents noted that meal delivery was more timely when a hospitality aide was scheduled, but this only occurred twice per week. The dietary manager and nursing home administrator were unaware of the extent of resident concerns, and the dietary manager stated that kitchen staff typically did not assist with tray delivery except during staffing shortages. The deficiency was further substantiated by group interviews during a resident council meeting, where multiple residents confirmed that room tray delivery was frequently late, sometimes by over an hour. Residents expressed that the delays were unacceptable and that they should not have to wait so long for meals, especially when the posted meal times were not being honored. The observations and interviews consistently demonstrated a pattern of late meal service for residents receiving room trays, with staff and management unaware or uninformed about the ongoing concerns.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene and use of personal protective equipment (PPE) during resident care. For one resident on enhanced barrier precautions (EBP) due to a urinary catheter, a CNA did not perform appropriate hand hygiene or don clean gloves while providing care, and an LPN did not wear a gown during high-contact care. Additionally, the resident's uncovered catheter drainage bag was observed on the floor, contrary to facility policy requiring catheter bags to be covered or shielded. During wound care for another resident with a right heel wound, an LPN failed to perform hand hygiene between glove changes while completing the dressing change procedure. The resident had severe cognitive impairment and required regular wound care as ordered in the medical record. The LPN acknowledged that hand hygiene should have been performed between glove changes, as confirmed by the Director of Nursing (DON). In a separate incident, a CNA providing perineal care to a resident with severe cognitive impairment and an open wound on the right lower leg removed soiled gloves and donned clean gloves without washing or sanitizing hands in between. The DON confirmed that hand hygiene should be completed between glove changes, especially after pericare. These observed failures to follow established infection control policies contributed to the deficiency cited by surveyors.
Failure to Assess and Monitor Cardiac Device Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and treatment for a resident who required cardiac monitoring. The resident, who had a history of hemiplegia, hemiparesis following a stroke, congestive heart failure, COPD, emphysema, and atrial fibrillation, was admitted with moderate cognitive impairment and was responsible for their own healthcare decisions. After a cardiology appointment, the resident returned to the facility with a cardiac monitor in place, but there was no documentation of new orders or instructions regarding the monitor. Staff did not assess the resident's ability to follow cardiac monitoring instructions, nor did they document any monitoring assessments, device checks, or symptom reporting related to the cardiac monitor. Interviews with staff revealed that the folder sent with the resident to the appointment was empty upon return, and no follow-up was conducted to obtain necessary paperwork or orders from the clinic. The LPN acknowledged that there was no documentation regarding the duration of monitor use, frequency of assessments, or device checks. The respiratory therapist who applied the monitor noted that the resident was unable to clearly express understanding of how to use the device. The DON confirmed that there was no documentation of follow-up or monitoring related to the cardiac monitor in the resident's medical record, and that such assessment and monitoring should have been included in the plan of care.
Failure to Provide Physician Orders and Proper Maintenance for CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents who required the use of continuous positive airway pressure (CPAP) machines. All three residents had medical conditions such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, obstructive sleep apnea, mesothelioma of the pleura, and respiratory failure, which necessitated the use of CPAP therapy. Despite these needs, the facility did not obtain or document physician's orders for the use, cleaning, or maintenance of the CPAP machines upon the residents' admission, as required by facility policy. Observations and interviews revealed that the residents were using CPAP machines without proper physician orders in place. One resident reported using their CPAP machine at night with settings from home and cleaning it independently, while another required staff assistance for cleaning and mask application but did not receive it. The surveyor observed that the CPAP equipment for two residents was visibly dirty, with masks and tubing containing skin particles, hair, dirt, and oil, and residents confirmed that staff had not cleaned the machines since admission. The facility's policy required verification of physician orders and regular cleaning and maintenance of CPAP equipment, including mask, tubing, and filters. However, the lack of timely physician orders and failure to assist residents with cleaning and maintaining their CPAP machines resulted in noncompliance with these requirements. Staff and leadership acknowledged during interviews that orders should have been obtained and cleaning performed as per policy, but these actions were not completed prior to the surveyor's findings.
Unauthorized Medication at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a resident was found with a tube of 1% hydrocortisone cream at their bedside without a physician's order or authorization to keep medication at the bedside. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine if a resident can safely self-administer medication and store it at the bedside. The resident's medical record did not contain an order for hydrocortisone cream, nor was there documentation of an assessment or care plan permitting self-administration or bedside storage of medication. Observations by the surveyor confirmed the presence of the cream at the bedside on multiple occasions, including once with the cap off. Interviews with the resident, an LPN, and the DON confirmed that the resident did not have an order for the cream or for self-administration, and the medication was not listed on the Medication Administration Record. The resident had intact cognition and was their own medical decision maker, but previous assessments indicated they did not wish to self-administer medication. The facility failed to follow its own policy and regulatory requirements for safe and accurate administration of drugs and biologicals.
Delayed Refund of Prepaid Fees After Resident Discharge
Penalty
Summary
The facility failed to refund a discharged resident's prepaid fees within the 30-day timeframe specified in the admission packet. Record review showed that a resident, who was cognitively intact and had diagnoses including benign neoplasm of cerebral meninges and hemiplegia, prepaid for services but was discharged before the end of the paid period. Despite the facility's policy to issue refunds within 30 days of discharge, the refund request was not processed in a timely manner. Documentation revealed that the refund was not issued until 73 days past the required 30-day period. The delay was attributed to issues with the facility's new accounts payable software, which caused the refund request to be overlooked. The administrator confirmed that the refund was owed and acknowledged the delay, noting that the system did not catch the refund in a timely manner. The resident's family member reported having to contact the facility multiple times before the refund was finally issued.
Failure to Accurately Transcribe Medication Orders and Notify Provider of Elevated Blood Glucose
Penalty
Summary
The facility failed to accurately transcribe and administer a prednisone taper as ordered for a resident who was readmitted following a hospital stay. The hospital discharge summary specified a tapering schedule for prednisone, but the orders entered into the electronic medical record (EMR) did not match the hospital's instructions. The medication administration record (MAR) showed inconsistencies in the dosage and administration dates, with some doses marked as refused and others not aligning with the prescribed taper. The resident reported receiving incorrect doses and missing doses on certain days. Additionally, the facility did not notify the provider of elevated blood glucose levels for the same resident, who had a diagnosis of diabetes mellitus. The resident's care plan included blood sugar monitoring as ordered by the physician, but the initial orders lacked specific parameters for when to notify the provider. Blood glucose readings over 400 mg/dL were recorded on two occasions, but there was no documentation that the provider was notified or that additional insulin or rechecks were performed. Staff interviews revealed uncertainty about notification protocols in the absence of explicit parameters, and the Director of Nursing confirmed that there was no evidence of provider notification for the elevated readings. The resident was cognitively intact and able to report her experiences, stating that staff did not respond to her high blood glucose readings and that she did not receive the correct prednisone taper. The facility's policies required medications to be administered as prescribed and for providers to be updated as needed, but these protocols were not followed in this case, resulting in the deficiencies identified.
Failure to Obtain Timely Wound Treatment Orders for Pressure Injuries
Penalty
Summary
The facility failed to obtain timely wound treatment orders when pressure injuries were identified for two residents. For one resident admitted with surgical aftercare and muscle weakness, a new mixed stage 1-2 pressure injury was identified during care, and although the medical doctor was notified and orders were reportedly received, no treatment orders were entered into the electronic medical record (EMR) during the resident's stay. The care plan did not address the pressure injury until several days later, and the wound was not entered into the facility's risk management system. Interviews with nursing staff and administration confirmed that the expected process of documenting the wound, obtaining and entering orders, and updating the care plan was not followed. Another resident, admitted with diabetes and vascular dementia, had a stage three pressure injury to the coccyx upon admission. Documentation showed that no treatment order for this wound was entered until two weeks after admission, despite the presence of the wound being noted in nursing assessments. The only order present on admission was for a moisture barrier cream, which was not signed off as administered. The facility's wound nurse confirmed that there was no wound nurse or system in place prior to her tenure, and that treatment orders were not obtained in a timely manner for this resident's pressure injury. Facility policy required collaboration with the interdisciplinary team, prompt skin assessments, provider notification, and timely updates to care plans and treatment orders for any abnormal skin findings. However, in both cases, the process for obtaining and documenting wound care orders was not followed, resulting in a lack of timely treatment for identified pressure injuries.
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