Citations in Wyoming
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wyoming.
Statistics for Wyoming (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Wyoming
- CNA #2 was suspended pending an investigation, an abuse allegation investigation was initiated, including resident interviews and reporting to appropriate entities, and education was provided to all staff on abuse reporting and investigation procedures. (K - F0610 - WY)
- Resident assessment was conducted, the involved CNA was suspended, the facility reported the incidents to the adult protection agency, state survey agency, and state board of nursing, and disciplinary action was taken against the perpetrators. (G - F0600 - WY)
- The facility implemented a Quality Assessment and Performance Improvement (QAPI) program addressing resident-to-resident abuse, placed the aggressive resident on increased and then one-to-one observation, provided staff training on behavior management and working with residents exhibiting aggression, and made plans to transfer the aggressive resident to another facility. (G - F0600 - WY)
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to respond to an allegation of abuse and protect a resident's right to be free from verbal abuse by a staff member. The incident involved a CNA who verbally abused a resident and attempted to physically move the resident against their will. The grievance was reported by another CNA and witnessed by an LPN, but the facility did not take immediate action to investigate or protect the resident. The abusive CNA continued to work multiple shifts following the incident, and the grievance was not logged in the facility's grievance log. Interviews with staff revealed that the incident was reported to the Business Office Manager (BOM), who asked the reporting CNA to document it in writing. Despite this, the grievance was not acted upon promptly, and the abusive CNA remained on duty. The facility's failure to investigate the abuse allegation and protect the resident led to a determination of immediate jeopardy. The facility's policy required immediate reporting and investigation of abuse allegations, which was not followed in this case.
Removal Plan
- CNA #2 was suspended pending an investigation.
- An abuse allegation investigation was started which included resident interviews and reporting of the allegation to the appropriate entities.
- Education was provided to all staff on abuse reporting notification and investigation which included education of oncoming staff before contact with residents.
Failure to Provide CPR According to Advance Directive
Penalty
Summary
The facility failed to provide CPR in accordance with a resident's advance directive, resulting in the resident's death shortly after admission. The resident had signed a POLST indicating a full code status, which was also signed by the physician. However, when the resident became unresponsive and lost signs of life, the staff did not initiate CPR. The administrator and the DON both believed the resident was a DNR/DNI based on information from the hospital and were unaware of the updated POLST. The POLST was not found in the disaster recovery binder at the nurses' station, and there was no documentation of the resident's mottling or physician notification prior to the resident's death. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's code status. The LPN who admitted the resident did not recall the resident's code status, and the social worker confirmed that medical records personnel processed the admission paperwork, including the POLST. The physician who signed the POLST was not notified of any concerns until the resident's death. The facility's policies on code blue and advance directives were not followed, leading to the failure to provide CPR as requested by the resident's advance directive.
Removal Plan
- Education to all staff regarding POLST forms and code blue.
- 100% audit of all POLST forms for all current residents.
- Audit of all licensed nurses for verification of up to date CPR.
- A mock Code Blue drill was conducted and would occur on every shift.
Resident Abuse and Neglect by CNAs
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as well as neglect, as evidenced by incidents involving two CNAs. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was left unattended in the bathroom and went unchecked for 13 hours during a CNA's shift. This neglect was captured on audio/video surveillance, and other staff reported concerns about the conditions of residents, such as saturated briefs and beds, and dried feces and urine left on beds. In another incident, the resident's daughter provided video footage showing a CNA verbally and physically abusing the resident. The footage showed the CNA pushing the resident in bed, pulling the resident up by one arm, and using aggressive and threatening body language. The CNA was also observed turning off the resident's call light and refusing to take the resident to the bathroom, leading to the resident expressing fear about calling for help. Interviews revealed that the CNA involved in the physical and verbal abuse had complained about being overwhelmed and needing help. The CNA stated that she had no intention of hurting the resident and was frustrated during the shift. The resident's daughter reported these incidents to the facility, and the resident exhibited new fearful behavior following the incidents.
Removal Plan
- Resident assessment
- CNA suspension
- Facility reported to adult protection agency, state survey agency, and state board of nursing
- Disciplinary action for the perpetrators
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in harm to two residents. Resident #5, who had moderate cognitive impairment and various medical conditions, was injured in an altercation with resident #1, who also had significant cognitive impairment and other health issues. During the incident, resident #1 entered resident #5's room, became agitated, and pushed resident #5, causing them to fall and sustain a fracture. This incident was documented in an incident report and confirmed through a facility investigation. A subsequent incident involved resident #1 entering the room of resident #2, who had significant cognitive impairment and multiple diagnoses. Resident #1 hit resident #2 on the shoulder, causing slight redness. This altercation occurred during a shift change when resident #1 was unsupervised, despite being on 1:1 observation. The facility's investigation substantiated both incidents, indicating a failure to adequately supervise and protect residents from abuse.
Removal Plan
- Implemented a quality assessment process improvement (QAPI) program addressing resident-to-resident abuse.
- Placed resident #1 on increased observation.
- Provided staff training including behavior management and working with residents with behaviors to decrease the risk of aggression towards other residents.
- Placed resident #1 on 1:1 observation.
- Plans made to transfer resident #1 to another facility.
Latest Citations in Wyoming
Multiple residents with severe cognitive impairment and behavioral challenges were involved in physical altercations, resulting in injuries such as a hematoma, abrasion, skin tear, and bruising. The incidents occurred when one resident followed others into a suite and was pushed, and when another resident entered a room uninvited, leading to a struggle. Insufficient supervision and ineffective implementation of care plan interventions contributed to the failure to prevent these incidents.
Several residents with severe cognitive impairment and behavioral challenges were involved in unwitnessed altercations, resulting in minor injuries, after one resident entered another's room and another was pushed to the floor. Both incidents occurred during a period of increased activity and insufficient supervision, despite care plans identifying risks and the need for staff intervention.
A resident with moderate cognitive impairment experienced a fall during a transfer, resulting in a wrist bruise. The CNA reported the incident to the nurse, but the resident's family was not notified as required by facility policy. The omission was discovered when the family member learned of the fall during a visit and contacted the facility with concerns.
A resident with severe cognitive impairment and a history of aggressive behaviors physically struck another resident on the head, despite existing care plan interventions and facility policies intended to prevent such incidents. The aggressive resident was later found to have a UTI, which had previously been linked to behavioral episodes. The resident who was struck cried out but was not injured.
Cloth gowns that were not fluid resistant were used by staff to sort contaminated laundry, as confirmed by the ADON. This practice did not meet CDC guidelines requiring gowns to be resistant to liquid and microbial penetration.
The facility failed to ensure proper infection control practices during meal service, as a CNA was observed assisting residents with eating and handling food without performing hand hygiene between residents. The CNA touched residents and their wheelchairs, and handled food items with ungloved hands, contrary to the facility's hand hygiene policy. The DON and infection preventionist confirmed the need for hand hygiene and glove use during meal service.
A facility failed to perform a gradual dose reduction (GDR) for a resident receiving trazodone for insomnia, despite recommendations from a pharmacist. The resident, who was cognitively intact, showed no documented episodes of restlessness. The physician declined GDR recommendations, citing clinical contraindications without providing specific documentation. The facility's policy emphasizes appropriate dosing and minimizing adverse effects, but these guidelines were not followed.
A resident with moderate cognitive impairment and multiple diagnoses experienced severe weight loss due to the facility's failure to provide adequate nutritional support. Despite being on a fortified diet with snacks, the resident was not offered snacks during extended periods at the dining table, and the care plan did not adequately address the need for frequent feedings. The dietitian confirmed that offering snacks was not documented in the resident's medical record, contributing to the resident's severe weight loss.
The facility did not have a qualified infection preventionist to manage the infection prevention and control program. The administrator was temporarily handling the responsibilities with help from the hospital, but no staff member had the necessary specialized training. The facility had 28 residents at the time.
The facility failed to document the education, offer, refusal, or receipt of influenza and pneumococcal immunizations for several residents. A review of medical records showed no evidence of required documentation for these vaccinations, and interviews with the administrator and DON confirmed the lack of evidence. The facility's policy requires such documentation, but it was not followed, resulting in the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse during a series of resident-to-resident altercations. One incident involved a resident with severe cognitive impairment and a history of wandering and entering others' personal space, who was pushed to the ground by another resident after following them into their suite. This resulted in the resident sustaining a hematoma above the left eyebrow and an abrasion under the left eye. The care plan for this resident had identified the risk of harm from others due to cognitive deficits, but interventions to prevent such incidents were not effectively implemented at the time of the altercation. Another incident involved a resident with severe cognitive impairment and anxiety who experienced distress when another resident entered their room without permission. The two residents were found on the floor kicking at each other after one entered the other's room, resulting in minor injuries including a skin tear, bruise, and scratch. The care plan for the resident who was protective of personal space included interventions to redirect other residents, but these measures were not sufficient to prevent the altercation. Staff interviews and documentation revealed that the facility was undergoing a transition that increased resident agitation and led to a rise in resident-to-resident incidents. The root cause was identified as insufficient supervision throughout the unit, which contributed to the failure to prevent these altercations. The lack of timely staff intervention allowed the incidents to escalate, resulting in actual harm to at least one resident.
Failure to Prevent Resident-to-Resident Altercations Due to Insufficient Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents involved in two unwitnessed resident-to-resident altercations. In one incident, a resident with severe cognitive impairment, non-traumatic brain dysfunction, Alzheimer's disease, and a history of wandering entered another resident's room. The second resident, also with severe cognitive impairment, Alzheimer's disease, Parkinson's disease, and anxiety, became agitated, resulting in both residents being found on the floor kicking at each other. Both sustained minor injuries, including a skin tear and bruising. The incident was unwitnessed, and the resident who was entered upon had a care plan indicating significant anxiety about others entering their room, preferring the door open but being highly protective of personal items. In another event, a resident with severe cognitive impairment and a history of being close to others was found on the floor near another resident's room. The second resident, also with severe cognitive impairment, hallucinations, delusions, and a history of verbal and physical behaviors, admitted to pushing the first resident, stating the other had been annoying. The incident was not witnessed by staff, and the resident who was pushed did not sustain injuries. Both residents had care plans identifying risks related to proximity to others and potential for physical aggression, with interventions to redirect and separate them as needed. The facility was undergoing a transition from two secure units to one, which increased resident activity and contributed to a rise in resident-to-resident incidents. Staff interviews and documentation revealed that insufficient supervision throughout the unit was identified as a root cause of these incidents. The lack of adequate staff presence and monitoring allowed for unwitnessed altercations to occur, despite existing care plans outlining the need for supervision and redirection for residents with behavioral challenges and cognitive impairments.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to notify the family member of a resident following a fall that occurred during a transfer. The resident, who had a moderate cognitive impairment and a history of cerebral infarction, experienced a fall when the resident pulled up a foot during a transfer, causing the CNA to lower the resident to the floor. The CNA reported the incident to the nurse on duty, but the resident's representative was not informed of the fall. The omission was discovered when the resident's representative visited and learned of the incident directly from the resident, who also showed a bruise on the wrist. Medical record review confirmed that the resident's representative called the facility to express concern about not being notified of the fall and a possible wrist injury. Subsequent assessment and x-ray showed no fracture, but a bruise and a small scab were noted. Staff interviews revealed that the nurse on duty at the time was a traveler and was unaware of the facility's policy requiring family notification after a fall. The facility's policy clearly states that family members must be notified in the event of a fall or possible injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with severe cognitive impairment and a history of agitation and aggression physically struck another resident on the head while the latter was being pushed down the hall by family. The aggressive resident had documented behaviors such as refusals, aggression, agitation, spitting, scratching, hitting, and exit seeking, and was known to exhibit both physical and verbal behaviors towards others. The care plan for this resident included interventions to protect the safety of others, such as removing the resident from situations and monitoring behavior episodes, but the incident still occurred. The aggressive resident was later found to have a urinary tract infection, which had previously been correlated with behavioral episodes. Following the incident, the resident who was struck cried out but was assessed and found to have no injuries. The aggressive resident was unable to be interviewed due to cognitive status. The facility's policy required evaluation of residents with a history of abuse to determine appropriate interventions to prevent harm to others, but despite these measures, the physical abuse incident occurred.
Non-Fluid Resistant Gowns Used During Laundry Sorting
Penalty
Summary
During an observation in the facility's laundry room, it was noted that cloth gowns were being used by staff to sort contaminated laundry. When water was placed on one of these gowns by the Assistant Director of Nursing (ADON), it was observed that the gowns were not fluid resistant, as the water penetrated the material. The ADON confirmed that the gowns lacked fluid resistance. According to CDC guidelines, gowns used in such settings must be resistant to liquid and microbial penetration, which was not the case in this instance. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Inadequate Infection Control During Meal Service
Penalty
Summary
The facility failed to implement proper infection prevention practices during meal delivery and assistance, as observed in two out of three meal observations in the main dining room. During one observation, a CNA assisted a resident with eating dinner and was seen touching the resident's shoulder, arm, and wheelchair wheel without performing hand hygiene. The CNA then moved to another resident, touching their hamburger with ungloved hands, cutting it, and handing it to the resident. The CNA continued to handle the resident's food, including a French fry, without washing her hands until after the meal service. In another observation, the same CNA assisted a resident by cutting their food and then touched the resident's shirt. The CNA proceeded to deliver meals to other residents, touching their wheelchairs and handling their food without performing hand hygiene between residents. The facility's Director of Nursing, infection preventionist, and dietary director confirmed that hand hygiene should occur between residents if contact occurs, and gloves should be worn when touching residents' food items. The facility's hand hygiene policy requires washing hands before and after resident contact and after handling potentially contaminated items.
Failure to Perform Gradual Dose Reduction for Antidepressant Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was performed for a resident reviewed for unnecessary medications. The resident, who was cognitively intact with a mental status score of 14 out of 15, had diagnoses including end-stage renal disease and insomnia. The resident was receiving trazodone, an antidepressant, for insomnia. Despite the absence of documented episodes of restlessness, the physician repeatedly declined pharmacist recommendations for a GDR, citing clinical contraindications without providing specific resident information. The physician's rationale included concerns about potential impairment of the resident's function or psychiatric instability, but these were not substantiated with detailed documentation. The Director of Nursing (DON) confirmed the lack of unsuccessful GDR attempts and the absence of specific documentation justifying the continued use of trazodone. The facility's policy on psychoactive medication management emphasizes the importance of seeking appropriate doses and minimizing adverse consequences, suggesting tapering when clinical conditions improve or stabilize. However, the facility did not adhere to these guidelines, as evidenced by the lack of documented attempts to reduce the medication dose or explore non-pharmacological interventions.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident with moderate cognitive impairment and multiple diagnoses, including dementia and chronic obstructive pulmonary disease. The resident was on a regular fortified low sodium diet with snacks, as per physician orders. However, the resident experienced a severe weight loss of 7.34% in one month, dropping from 88.5 lbs to 82.0 lbs. Observations revealed that the resident, who appeared very thin with hollow cheeks and temples, was not offered snacks during extended periods at the dining table, despite the care plan indicating the need for small, frequent feedings and snacks. The dietitian confirmed that offering snacks was not a documented task in the resident's medical record, although it was expected that staff offer snacks, particularly between lunch and dinner. The facility's policy on weight assessment and intervention indicated that a weight loss greater than 5% in one month is severe and requires a multidisciplinary care plan. However, the resident's care plan did not adequately address the need for snacks, and there was no documentation of snacks being offered or accepted over a month-long period, contributing to the resident's severe weight loss.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure a qualified infection preventionist was designated to oversee the infection prevention and control program. During an interview with the facility administrator, it was revealed that the position of infection preventionist was vacant. The administrator was managing the program with assistance from the hospital, but confirmed that no staff member had completed specialized training in infection prevention and control. The facility had a census of 28 residents at the time of the survey.
Failure to Document Immunization Education and Administration
Penalty
Summary
The facility failed to document the education, offer, refusal, or receipt of influenza and pneumococcal immunizations for four out of six sampled residents. Specifically, the immunization records for these residents lacked evidence of education about the benefits and potential side effects of the vaccines, as well as documentation of whether the vaccines were offered, refused, or administered. This deficiency was identified through a review of the medical records of residents #12, #14, #24, and #28, which showed no documentation of the required information for influenza, pneumococcal, and in some cases, COVID-19 vaccinations. An interview with the facility's administrator and director of nursing confirmed that the facility did not have evidence that the immunizations were offered or provided to the affected residents. The facility's policy, last updated in March 2022, mandates that residents or their legal representatives be educated about the vaccinations and that this education, along with any refusal or administration of the vaccines, be documented in the medical records. However, this policy was not followed for the residents in question, leading to the identified deficiency.
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