Citations in California
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in California
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident was discharged without the required physician documentation indicating that their health had improved sufficiently and that they no longer needed facility services. The medical record did not show that the physician assessed the resident for a safe discharge prior to the planned discharge date, as required by facility policy.
A resident with a dehisced surgical wound did not have Enhanced Barrier Precautions (EBP) implemented, despite physician orders for wound care and facility policy requiring EBP for such cases. Observations revealed no PPE set-up or EBP signage, and staff confirmed that EBP was not in place. The DON and Administrator verified the absence of EBP and related precautions for the resident.
Three residents were affected when the facility did not provide necessary care to prevent accidents, including a resident who left unsupervised and fell, and two residents who did not receive required post-fall neuro checks as outlined in their care plans. Staff confirmed that education on safety and completion of assessments were not documented as required.
Two residents with cognitive impairment and significant medical conditions were involved in a physical altercation after one became verbally aggressive and struck the other. A CNA present attempted to verbally de-escalate but did not immediately separate the residents or call for help, contrary to facility policy. This lack of prompt intervention resulted in one resident being hit.
A resident with cognitive impairment and total dependence for transfers was moved from a wheelchair to a bed using a Hoyer Lift by a CNA without the required second staff member. Staff interviews and documentation confirmed that a two-person assist was necessary per care plan, facility policy, and manufacturer guidelines, but this protocol was not followed during the transfer.
During an electrical fire in the main panel room, staff failed to activate the manual fire alarm as required by facility policy. Instead, staff called 911 and notified others verbally, but did not use the nearest manual pull station, resulting in the fire alarm not being triggered and the facility not being fully alerted.
Surveyors found that the facility did not have documentation showing its emergency generator had undergone a required four-hour continuous load test within the past 36 months. Administrative and maintenance staff were unable to provide evidence of compliance, and the only available service report showed a test duration of just over three hours, not meeting regulatory standards.
A resident with severe cognitive impairment and multiple diagnoses did not have their oral intake documented for several meals, as required by care plans and facility policy. A CNA failed to record this information, citing lack of access to the charting system, and multiple staff confirmed that such documentation is essential for monitoring nutrition and health. Review of records showed missing documentation on several days, resulting in incomplete medical records.
A resident was found self-administering multiple medications at bedside without a required assessment, physician's order, or care plan documentation. Staff confirmed that the resident was not authorized to have medications unattended and that facility policy requiring IDT assessment and documentation was not followed.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Document Physician Assessment Prior to Resident Discharge
Penalty
Summary
The facility failed to ensure that the discharge process was properly followed for one of three sampled residents. Specifically, the medical record for the resident did not contain documentation from the physician indicating that the resident's health had improved sufficiently to warrant discharge from the facility. There was also no evidence that the physician had assessed the resident for a safe discharge prior to the planned discharge date. The facility's policy and procedure on transfer or discharge requires that the physician document the medical reasons for transfer or discharge in the medical record, except in cases of nonpayment or facility closure. Additionally, a copy of the physician's order for discharge should be attached to the discharge notice. In this case, although there was a physician's order indicating a possible discharge to a program with home health for safety evaluation, the medical record lacked documentation that the resident was assessed and determined to be ready for discharge by the physician. The resident involved had the capacity to understand and make decisions, as indicated by a prior history and physical examination. However, the absence of physician documentation regarding the resident's readiness for discharge and the lack of an assessment for a safe discharge were confirmed during a telephone interview with the Administrator, who verified the findings. This failure had the potential to result in an unsafe discharge for the resident.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1 was affected by this deficient practice. Resident 1 is still residing in the facility. On 8/25/2025, IDT team notify primary care physician about discharge planning for resident 1. On 8/25/2025, Administrator in-serviced IDT team about facility policy and procedure for discharge planning and process. Administrator emphasize the need to involve primary care physician during discharge process to make sure PCP can assess and document resident's care needs and if safe for discharge. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All discharged residents were potentially affected by this deficient practice. On 8/25/2025, Medical records audited all residents discharged in the last 30 days for physician documentation and found no other issue. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: Administrator or designee will oversee the discharge planning and process. IDT team will initiate discharge planning during initial care plan meeting and notify PCP of the initial plan. Any resident found by IDT that indicated their health significantly improved, PCP will be notified and assess if resident is safe for discharge and document in their progress notes and order for discharge. If PCP agreed and documented that resident is safe for discharge, IDT team will start discharge process and notify the resident or responsible party. Medical record will audit all discharge residents' medical records to make sure compliance x 3 months. Any non-compliance will be reported to the Administrator. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will report any findings and present them to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 09/11/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/30/2025 Audit all discharge residents' medical records to make sure compliance x 3 months. Any non-compliance will be reported to the Administrator. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: Administrator will report any findings and present them to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 09/11/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/30/2025
Failure to Implement Enhanced Barrier Precautions for Resident with Surgical Wound
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for a resident with a surgical wound. The resident, who had a history of cranioplasty and a slowly healing, dehisced surgical wound, was admitted and readmitted to the facility. Physician orders were in place for daily wound care, including cleansing and dressing changes for both the scalp and left temple wounds. However, there was no physician order for Enhanced Barrier Precautions (EBP), which are required for residents with wounds at high risk for colonization with multidrug-resistant organisms (MDROs). During observations, the resident was found in bed with wound dressings but without any PPE set-up or EBP signage outside the room. Interviews with the LVN and Infection Preventionist (IP) confirmed that EBP was not implemented, despite both acknowledging that EBP should have been in place due to the resident's surgical wound. The IP also verified the absence of a physician's order for EBP and the lack of necessary precautions. Further review and interviews with the Director of Nursing (DON) and the Administrator confirmed that the resident had a surgical wound and that EBP, including PPE set-up and signage, was not implemented as required. The facility's failure to follow its own infection prevention and control policies and procedures resulted in the deficiency, as the necessary precautions to prevent the transmission of communicable diseases or organisms were not in place for the resident.
Plan Of Correction
F0880 signage, orders and care plans were in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Infection Preventionist/Designee conducted an in-service from 8/5/25 - 8/12/25 to licensed nurses regarding EBP practices and the criteria that would require implementation. Infection Preventionist will make daily rounds and audit new admissions and current residents on EBP, Monday - Friday x 3 months to ensure proper implementation of EBP on the floor that includes signage, orders and care plans are in place. DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025 DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025
Failure to Prevent Accidents and Complete Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services to prevent accidents for three residents. One resident left the facility unsupervised after dinner without informing staff and was pulled by another resident on an electric chair. While passing over a gate frame, the resident's chair tilted, causing her to fall and land on her right shoulder. Although there were no head or skin injuries and vital signs were normal, the resident was transferred to an acute care hospital. The care plan for this resident included interventions such as educating her on the importance of informing staff before leaving the facility and explaining the risks of not doing so. However, there was no documented evidence that this education or explanation of risks was provided. Additionally, the resident's smoking assessment was not completed upon readmission, as verified by staff review. Two other residents experienced falls and were placed on care plans that required post-fall neurological checks for 72 hours. One resident was found sitting on the floor with no injuries, and the other was found lying on the floor after attempting to reach for a diaper, also with no injuries. Despite care plan interventions specifying neuro checks, medical record reviews for both residents failed to show any documented evidence that these assessments were completed following their falls. Staff interviews confirmed that neuro checks should have been performed and documented, but no such documentation was found. The Director of Nursing and other nursing staff verified the lack of documentation for both the education regarding leaving the facility and the required post-fall neuro checks. The facility's policies and procedures require comprehensive care planning, accurate assessments, and documentation of all relevant care and interventions, but these were not followed in the cases reviewed. These failures had the potential to negatively affect the health and well-being of the residents involved.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: For Resident 1, who was directly affected, corrective actions were taken immediately. On 8/1/25, the resident was re-educated by the DON and SS on the facility's out-on-pass policy, including the requirement to notify staff before leaving the premises. The charge nurse will monitor the signing in and out book. The resident was also informed of the potential dangers and/or risks associated with going out on pass, including the possibility of accident or injury. Specific safety concerns were addressed, such as nearby streets with vehicle traffic, and environmental hazards like uneven pavement, gravel, curbs, driveways, sidewalk cracks, steps, and stairs. This education was provided verbally and acknowledged in writing by the resident. A smoking assessment for Resident 1 was accurately completed by the LN per facility procedure, and all documentation was placed in the medical record on August 1, 2025. Residents 2 and 3 did not experience any harm as a result of the missed post-fall neuro checks. Both residents have since been discharged from the facility in accordance with their individual discharge plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, regarding their responsibility to initiate and document all resident education about the risks of leaving the facility without staff notification and monitoring the sign-in and out book. The RN Supervisor or designee reviews the resident signing in and out book daily for completeness and accuracy. To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to complete smoking assessments for all identified smokers at admission, re-admission, and quarterly. Medical Records verifies weekly that all residents identified as smokers have a current smoking assessment for completeness and accuracy. The DON and Medical Records director are responsible for ensuring these processes are maintained. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to initiate post-fall neuro checks in accordance with the facility's policy. The RN supervisor or designee now reviews all changes of condition daily to ensure neuro checks are initiated and documented. The DON and Medical Records Director are responsible for ensuring these processes are maintained. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. To ensure sustained compliance, the Medical Records conducts daily audits of the residents with an out-on-pass orders. The RN Supervisor or designee will monitor the completeness and accuracy of the signing-in and out book. Any omissions are reported immediately to the DON for corrective action and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the out-of-the-facility education and monitoring of the sign-in and out book for completeness and accuracy. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records completes a weekly review of smoking safety assessments for all identified smokers, ensuring they are complete, accurate, current, and incorporated into the care plan. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the smoking assessments for completeness, accuracy, currency, and incorporation into the care plan. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records conducts daily audits of all new falls to verify neuro checks and resident education are documented. Any omissions are reported immediately to the DON for corrective actions and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews care plan compliance quarterly to confirm interventions for falls. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. Compliance will be submitted to the QA committee monthly (Aug-Sep-Oct) or until substantial compliance is maintained. The Administrator will ensure compliance.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate staff supervision for two residents, resulting in a physical altercation. Both residents had moderately impaired cognitive skills and required varying levels of assistance with daily activities. One resident, who had end stage renal disease, COPD, and diabetes, was struck on the left side of the face by another resident with a history of urinary tract infection, bilateral below-knee amputation, and COPD. The incident occurred when the second resident, while sitting in his wheelchair and eating lunch, became verbally aggressive and called the first resident names, telling him to get out of the way. A certified nurse assistant (CNA) was present in the room and observed the verbal aggression. The CNA stood between the two residents and attempted to verbally de-escalate the situation by telling the aggressive resident to be nice. Despite this, the aggressive resident suddenly hit the other resident. The CNA later acknowledged that she should have separated the residents immediately or called for help, and that the incident could have been prevented with prompt action. Interviews with facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the facility's policy requires immediate separation of residents during altercations to prevent harm. Review of facility policies also indicated that resident safety, supervision, and prompt intervention during altercations are priorities. The failure to separate the residents promptly and provide adequate supervision directly led to the physical altercation and the resulting deficiency.
Plan Of Correction
F689 Corrective action for residents found to have been affected by this deficiency: CNA 1 was provided a one-on-one in-service and education regarding immediate separation and de-escalation of potential resident-to-resident altercation on 8/4/25. Corrective action for residents that may be affected by this deficiency: On 7/31/25, the Director of Staff Developer/designee interviewed staff to identify any resident roommate incompatibility to ensure supervision and communication to prevent potential resident incidents. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above Plan of Correction (POC) will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/4/25 and 8/5/25, the DON/designee provided an in-service and education training to staff regarding the facility’s policies and procedures on resident-to-resident altercation; to act promptly and conscientiously to prevent and address recurrent altercations, separate immediately, and measures to calm or diffuse the situation. The Director of Staff Developer/designee will validate compliance during observation rounds daily, checking if staff are responding immediately to potential resident incidents. The Director of Staff Developer/designee will communicate findings to the DON. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. The Administrator and/or Designee will report trends.
Failure to Use Two-Person Assist During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a required two-person assist during a Hoyer Lift transfer for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including metabolic encephalopathy, vascular dementia, and cerebral infarction, was dependent on staff for all transfers and unable to make decisions or support himself. Despite care plan interventions and physical therapy recommendations indicating the need for full assistance, a certified nursing assistant (CNA) transferred the resident from a wheelchair to a bed using the Hoyer Lift without a second staff member present. Multiple interviews confirmed that facility policy, the resident's care plan, and the manufacturer's guidelines all required two staff members for Hoyer Lift transfers to ensure safety. The CNA, as well as other staff including an LVN, RN, DON, and Director of Rehab, acknowledged that a two-person assist was necessary for this resident due to his cognitive and physical limitations. The incident was directly observed and reported by the responsible party, and documentation supported that the resident was fully dependent and at risk during transfers.
Plan Of Correction
Corrective Action: Res1 is currently in the hospital. RN will assess Res 1 regarding transfer assistance needs upon return. On 7/31/25, the DON/DSD provided CNA1 1:1 service/disciplinary action regarding the need to exercise clinical judgement when operating a Hoyer lift with another staff. How to Identify Potentially Affected: On 7/29/25, the charge nurses checked other residents requiring Hoyer lifts for transfers to ensure the staff is operating it safely, with another staff assisting as needed. No similar issues identified. Systematic Change: On 7/30-31, 2025, the DSD/Designee (Director of Staff Developer) in-serviced the licensed nurses and licensed nurses on the facility's policy on operating Hoyer lifts with additional staff based on staff's clinical judgment, to ensure resident's safety. The facility will continue to have visual identifiers for the use of Hoyer lifts to alert CNAs and Licensed nurses. The DSD will complete the CNAs' skills competency on how to safely operate the Hoyer lift upon hire, annually, and as needed. MONITORING: The DON/Supervisors/Charge Nurses will monitor compliance with proper use of Hoyer lifts through routine rounds. The facility will conduct a QA study on staff compliance to the use of Hoyer lifts in the next 30 days or until acceptable compliance is achieved. If lack of compliance is identified, revisions will be made as needed. Trends and findings will be reported to the QA committee for further recommendations. Completion date: 8/10/25
Failure to Activate Fire Alarm During Electrical Fire
Penalty
Summary
The facility failed to follow its own Fire Policy during an incident in which the main electrical panel room's switchboard caught fire. When smoke was discovered, staff members responded by calling 911 and notifying other staff, but did not activate the manual fire alarm system. The fire alarm did not trigger automatically, and no one pulled the nearest manual fire alarm, which was located near the exit doors by Resident Room 17 and the Director of Staff Development's office. This omission was confirmed through interviews with the Director of Staff Development and the Maintenance Supervisor, as well as direct observation of the location of the manual pull station. A review of the facility's Fire Policy indicated that staff are required to alert others over the intercom and pull the nearest fire alarm in the event of a fire. Despite this clear directive, staff did not follow the procedure, resulting in a failure to alert all individuals in the facility during the fire event. The deficiency was identified through interviews, record review, and observation, and it affected the safety of all 49 residents, staff, and visitors present at the time.
Plan Of Correction
K 0711 Corrective action for residents found to have been affected by this deficiency: On 07/28/2025, the Administrator provided a 1:1 in-service to the Director of Staff Development (DSD) and to Housekeeping 1 (HSK 1) on the Facility's Fire Policy and Procedure; and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Corrective action for residents that may be affected by this deficiency: On 07/27/2025, 07/28/2025, and 08/03/2025, the DSD provided an in-service to department heads, nurses, dietary, activity, housekeeping/laundry, maintenance, and other staff on the Facility's Fire Policy and Procedure and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Measures that will be put into place to ensure that this deficiency does not recur: During daily rounds, the DSD will randomly ask staff members on all shifts what to do in case of fire to ensure pulling the fire alarm is identified. Discussion on activating the fire alarm will be part of the monthly fire drills performed by the facility's Fire Life Safety & Security vendor. During the initial orientation, the DSD will ensure new hires will be familiar with the facility's Fire Policy and Procedure, including pulling the fire alarm. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use the indicator, "Fire Drill Program," monthly, to ensure staff
Failure to Document Four-Hour Emergency Generator Load Test
Penalty
Summary
The facility failed to provide documentation that its emergency generator underwent a required four-hour continuous load test within the past 36 months, as mandated by NFPA 110 standards. During the survey, the Administrator and DON were unable to produce written documentation of the most recent four-hour generator load test when requested. The Administrator indicated that the Maintenance Supervisor (MS) might have the documentation, but he was unavailable at the time due to being on vacation. Upon the MS's return, a generator service report dated 9/21/2021 was provided, which indicated that the emergency generator was tested for only 3 hours and 15 minutes, falling short of the required four-hour duration. No other documentation was available to demonstrate compliance with the four-hour continuous load test requirement within the last 36 months. The MS acknowledged the absence of a four-hour load test during an interview with the surveyor. The deficiency was identified through observation, interviews, and record review, and it affected all three smoke compartments of the facility. The lack of proper documentation and completion of the four-hour generator load test was confirmed by both administrative and maintenance staff during the survey process.
Plan Of Correction
has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be put into place to ensure that this deficiency does not recur: has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. On 07/28/2025, the Administrator provided a 1:1 in-service to the Maintenance Supervisor to ensure a continuous four-hour emergency generator load test is conducted every 36 months. The Maintenance Supervisor will conduct an annual maintenance record review to ensure a continuous four-hour emergency generator load test is conducted within 36 months. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025.
Failure to Document Resident Oral Intake
Penalty
Summary
The facility failed to ensure that nursing records were completely and accurately documented by not recording the oral intake for a resident with significant cognitive impairment and multiple diagnoses, including Alzheimer's disease, dementia, and anemia. The resident required varying levels of assistance with daily activities and had care plans in place to monitor nutritional status and address unplanned weight changes. The care plans specifically required staff to monitor, record, and report oral intake at each meal to maintain adequate nutrition and identify potential issues. On at least one occasion, a Certified Nursing Assistant (CNA) did not document the resident's oral intake for breakfast and lunch, citing lack of access to the charting system as the reason. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Assistant Director of Nursing (ADON), confirmed that CNAs were expected to document meal percentages after each meal as part of their responsibilities. The ADON reviewed the resident's Nutrition Report and found missing documentation of oral intake for multiple days, emphasizing that lack of access to the charting system was not an acceptable reason for failing to document. Review of the CNA job description and facility policies further confirmed that recording residents' oral intake is a required duty. Facility policies also stated that documentation should be complete, factual, and promptly recorded to accurately reflect services provided. The failure to document oral intake as required resulted in incomplete medical records and had the potential to disrupt communication among staff and delay necessary care for the resident.
Plan Of Correction
A. How corrective actions will be accomplished for those residents found to be affected by the deficient practice? a) On 7/25/25, CNA 1's access to PointClickCare (PCC) was reviewed, and CNA1 PCC password was reset by the Administrator to ensure proper access to the electronic documentation system. b) On 7/28/25, CNA 1 documented Resident 5's food intake for all meals to ensure that current data was recorded. c) On 7/26/25, the Director of Nursing (DON) reviewed Resident 5's weights and there was no impact as a result of the documentation failure. d) On 7/25/2025, CNA 1 received a 1:1 in-service training on the importance of timely and accurate documentation of resident food intake after each meal. The training also emphasized the requirement to immediately notify a supervisor, the Director of Staff Development (DSD), or the Administrator if there are any access issues with the PCC system. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a) All residents who were identified as having nutritional or weight related issues are at risk due to this deficient practice. b) The DON or Medical Records Director (MRD) conducted a facility-wide audit of oral intake documentation for all residents with nutritional risk or weight-related care plans was initiated on 7/25/25 and completed by 7/28/25. c) There were no additional residents identified with deficiencies related to the documentation of food intake. C. What measures will be put in place or what systematic changes the facility will make to ensure that the deficient practice does not recur? a) On 7/28/25, mandatory re-education was provided to all CNAs, LVNs, and RNs on: The importance of accurate, timely documentation of oral intake. The requirement to report immediately if PCC access is unavailable or not functioning. b) On 7/28/25, the Director of Staff Development (DSD) reviewed the PCC access status of all CNAs to identify and resolve any issues with login credentials or system access. c) The DON or Medical Records Director will perform random daily audits of oral intake documentation using audit tools for 10 residents daily x3 days, then weekly for 4 weeks, and monthly thereafter for 3 months. Any staff found not documenting resident food intake were immediately re-educated by the DSD or DON. D. How the facility plans to monitor its performance to make sure the solutions are sustained? a) All audit findings related to oral intake documentation and identified trends will be presented during the monthly QAPI meetings by the Facility Administrator, Director of Nursing (DON), and Medical Records. b) Any patterns of non-compliance will result in immediate corrective actions, including individual coaching, counseling, and re-training of involved staff. c) The QAPI Committee will continue to monitor oral intake documentation compliance for a period of 3 months, or until sustained compliance is achieved.
Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed with a medication cup containing multiple medications at their bedside and proceeded to self-administer these medications without the presence of a licensed nurse. The resident's medical record did not contain an assessment, physician's order, or care plan addressing the ability to self-administer medications. The facility's policy requires that the interdisciplinary team (IDT) assess the safety of self-administration, clarify physician orders to include "may keep at bedside," and document these determinations in the care plan, none of which were completed for this resident. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not supposed to have medications unattended at the bedside and that the required assessment and documentation were missing. The medications involved included blood pressure medications, blood thinners, and supplements. The DON verified that the resident's records lacked the necessary assessment, physician's order, and care plan problem for self-administration of medications, in direct violation of facility policy and federal requirements.
Plan Of Correction
Corrective Action for those residents identified as being affected by this deficiency: Resident 3 was assessed by the DON if he wishes to self-administer medications on 7/24/2025 and resident declined. Identification of other residents having the potential to be affected by this same deficiency: All residents have the potential to be affected by the same deficiency. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. How the facility will monitor its performance to make sure that solutions are sustained: Documented findings of the audit will be forwarded to the QAPI committee monthly for at least 4 weeks beginning September 2025 for review and action planning as indicated or as the QAPI committee determines compliance.
Some of the Latest Corrective Actions taken by Facilities in California
- Provided facility-wide in-service training on medication-administration policies, emphasizing verification of resident and drug information, parameter-based holds, and physician notification (K - F0760 - CA)
- Delivered targeted one-on-one coaching to identified nurses on Epogen administration according to laboratory parameters (K - F0760 - CA)
- Created a dedicated Epogen injection log and instituted weekly audits of orders, MARs, and laboratory values to confirm parameter compliance (K - F0760 - CA)
- Launched a QAPI initiative to monitor Epogen practices and adjust measures for ongoing state and federal compliance (K - F0760 - CA)
- Conducted in-service education for all licensed staff on reconciling GACH discharge orders, resolving discrepancies, and monitoring anticoagulant side-effects (J - F0684 - CA)
- Assigned RN Supervisor to review clinical-alerts reports daily for continuity-of-care issues and bleeding indicators (J - F0684 - CA)
- Required DON/ADON or RN Supervisor to perform medication reconciliation against GACH discharge orders for every new admission (J - F0684 - CA)
- Implemented a QAPI Performance Improvement Project with daily audits of discharge-order compliance, anticoagulant use, and adverse-effect monitoring (J - F0684 - CA)
- Engaged Quality & Safety consultant to audit medication reconciliation and anticoagulant monitoring for newly admitted residents (J - F0684 - CA)
- Mandated monthly submission of audit results to the QAA committee for oversight until sustained compliance is achieved (J - F0684 - CA)
Significant Medication Errors: Epogen Administered Outside Physician Parameters
Penalty
Summary
The facility failed to ensure that two residents were not administered Epoetin Alfa-epbx (Epogen) injections outside of the parameters specified in their physician orders. Both residents had orders to hold Epogen injections if their hemoglobin (Hgb) levels exceeded 10 g/dl. Despite these clear instructions, staff administered multiple doses of Epogen to both residents when their Hgb levels were above the prescribed threshold. One resident, with a history of end stage renal disease, dependence on dialysis, and anemia, received 19 unnecessary doses of Epogen over a period when their Hgb level was documented at 11.5 g/dl. The medication administration records and interviews with licensed vocational nurses revealed that the nurses did not check the most recent Hgb levels or review the physician's order before administering the medication. The nurses acknowledged that they failed to follow the order to hold the medication and recognized this as a medication error. Another resident, with a history of kidney transplant and anemia, received three unnecessary doses of Epogen when their Hgb levels were 12.3 g/dl and 12.9 g/dl. The nurse responsible admitted to not checking the latest Hgb level or reading the physician's order accurately before administration. The Director of Nursing confirmed that the facility did not follow the physician's orders and that licensed nurses were required to check current Hgb levels before administering Epogen. Facility policy required medications to be administered as prescribed, including adherence to any parameters set by the physician.
Removal Plan
- Notify the pharmacist regarding Resident 35 receiving extra doses of Epogen injections.
- Communicate with the Nephrologist to have the dialysis center administer Epogen injections based on lab work during dialysis treatments.
- Follow up with Resident 35's Primary Physician to clarify the order for Epogen to be given at the dialysis center.
- Assess Resident 35 for overall health condition and status.
- Notify Resident 89's Primary Physician regarding Resident 89 receiving extra doses of Epogen injections when Hgb was above the prescribed parameter.
- Continue the Epogen order for Resident 89 with the same parameter (hold Epogen injections when Hgb > 10 mg/dl), pending a complete blood count result.
- Notify the pharmacist regarding Resident 89 receiving Epogen injections when Hgb was above the prescribed parameter.
- Assess Resident 89 for overall health condition and status.
- Notify the Medical Director of the Immediate Jeopardy and develop a removal plan.
- Notify all licensed nurses of the Immediate Jeopardy findings and provide in-services regarding the Medication Administration policy and procedure, including checking/verifying resident and medication information, holding/discontinuing medication per parameters, and notifying physicians of medication-related issues.
- Notify the specific RN and LVNs responsible for the identified findings and provide one-on-one in-services regarding medication administration policy, focusing on Epogen injection administration based on parameters, following disciplinary action.
- Complete in-services regarding medication administration policy and procedure for all licensed nurses.
- Initiate a Quality Assurance and Performance Improvement (QAPI) plan to address the findings.
- Review all current residents with Epogen injection orders.
- Provide in-service regarding medication administration policy and procedure for all licensed nurses.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed to ensure compliance.
- Create an Epogen injection administration log including resident name, Epogen injection order, medication administration following parameter, and laboratory monitoring.
- Review all residents with Epogen injection orders, medication administration records, and laboratory results after admission, then weekly and as needed, and document findings with corrective action on the monitoring log.
- Review the QAPI program and adjust measures to ensure effective and ongoing compliance with State and Federal regulations.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of nontraumatic intracerebral hemorrhage in the brain stem, severe cognitive impairment, and at risk for elopement was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident had previously been assessed as low risk for elopement, but on the day of the incident, was observed by a CNA packing belongings and expressing a desire to leave. Despite this, the resident was not immediately reassessed for elopement risk, and no detailed monitoring plan or interventions were implemented in accordance with the facility's elopement policy. Staff, including the DON and Social Services Assistant, were made aware of the resident's intent to leave and were instructed to monitor the resident and ensure the facility doors were supervised. However, the doors were not continuously monitored, as the receptionist responsible for this task was not present and no other staff were specifically assigned to this duty. As a result, the resident was able to exit the facility undetected, travel to a previous residence, and remain away from the facility for over six hours before being returned by an unidentified individual. Interviews and record reviews confirmed that staff failed to follow the facility's policy and procedure for elopement prevention, including reassessment of risk and implementation of appropriate interventions when a resident demonstrates behaviors such as packing belongings and verbalizing a desire to leave. The lack of immediate supervision and failure to monitor facility exits directly led to the resident's elopement.
Removal Plan
- Resident agreed to be transferred to the acute care hospital for further evaluation. The attending physician issued the order for transfer.
- Resident will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document.
- The facility will implement 24-hour monitoring of the doors to strive and prevent harm to all our patients.
- Resident refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived.
- Received orders from physician to apply a wander guard to Resident.
- Obtained informed consent from Resident's Responsible Party (RP).
- Resident continued to refuse the wander guard despite several attempts and education on safety. Physician and Resident's RP made aware.
- Resident will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring.
- Resident's elopement assessment was updated to reflect Resident being at high risk for elopement.
- Situation, Background, Assessment Recommendation (SBAR) documentation initiated for Resident and 72-hour SBAR documentation initiated.
- Resident's care plan was updated with interventions implemented to prevent a repeat event.
- Resident spoke with a psychiatrist via resident's telephone for evaluation for psychological support and emotional distress. The psychiatrist ordered a follow-up with social services for discharge. Resident was placed on psychological monitoring.
- Resident will be seen by a psychologist for evaluation for psychosocial distress related to the recent event of elopement.
- All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated.
- Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI) committee to identify other residents who have the potential to be affected.
- Care plans will be updated for all residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety.
- The facility has identified only one resident at high risk for elopement which is Resident.
- The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring.
- The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur.
- The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced staff members concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well.
- The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement.
- The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises.
- The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman, and CDPH.
- The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation.
Failure to Verify Discharge Orders and Monitor Anticoagulant Use Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and services in accordance with professional standards of practice for a resident who had recently undergone lumbar decompression and fusion surgery. The facility did not ensure that the admitting RN reviewed and verified the hospital discharge records with the attending physician, specifically regarding the start date for Plavix, an antiplatelet medication. The hospital discharge orders clearly indicated that Plavix was to be started nine days after admission, but the facility's licensed nurses began administering the medication immediately upon admission, based on an incomplete faxed medication list that lacked start dates. The facility also failed to provide continuity of care by not following the neurosurgeon's specific order to delay the initiation of Plavix. The medication was administered for four days prior to the intended start date, and there was no evidence that the nurses clarified the discrepancy with the attending physician. Additionally, the facility did not assess, monitor, or document the resident for signs and symptoms of bleeding, hematoma, or hemorrhage, despite the resident's recent spinal surgery and use of an antiplatelet medication, both of which increased the risk for such complications. As a result of these failures, the resident experienced a change of condition, becoming unresponsive and requiring emergency transfer to a hospital, where imaging revealed multiple intracranial hemorrhages. The resident subsequently died, with the immediate cause of death listed as nontraumatic intracranial hemorrhage. Interviews with facility staff and physicians confirmed that the medication was given earlier than ordered and that appropriate monitoring and verification of orders did not occur.
Removal Plan
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding reviewing and verifying any discrepancies with the ordering physician by clarifying the faxed medication discharge order and the GACH discharge papers that were given to the resident. In addition, clarify medication orders that are missing the start and end dates.
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding monitoring the resident status post-surgery and the use of anticoagulant therapy for potential side effects such as signs/symptoms of bleeding.
- The DON and designee provided in-service to the licensed nurses regarding: Review and verify GACH discharge orders with facility's attending physician. Status post-surgery residents with anticoagulant use and signs/symptoms of bleeding. Following GACH discharge orders. Any licensed staff, who were not present, the DON will do in-service education upon returning to work.
- Residents on anticoagulants were assessed for any signs/symptoms of bleeding, potential side effects of anticoagulant use and black box warning monitoring.
- The Registered Nurse (RN) Supervisor will check clinical alerts report daily for any COC and any signs/symptoms of bleeding.
- DON, ADON or RN Supervisor/designee will conduct medication reconciliation with the residents GACH discharge orders and admitting orders carried out by licensed nurse.
- Newly admitted residents will have random audits following GACH discharge orders and completion of medication reconciliation. Three residents weekly for four weeks, then two residents weekly for two weeks, then two residents a month for two months. Inservice would be given to licensed nurses involved. Findings will be presented in the monthly QAA meeting.
- DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) for the following: Review and verify GACH discharge orders with attending physician. Use of anticoagulant and its side effects. Following GACH discharge orders. PIP resulted in DON/ADON doing daily audits in reviewing compliance for following GACH discharge orders, continuity of care, use of anticoagulant and identification of potential adverse side effect of the medication.
- The Quality and Safety (QS) RN/Consultant will complete audits on medication reconciliation, the use of anticoagulants, and its side effects for newly admitted residents.
- ADM, DON or Designee will submit audit findings to QAA committee monthly until compliance is met.
- The facility will develop a QAPI-PIP for the use of anticoagulant to be submitted in the next QAA committee meeting.
- ADM and DON are responsible for implementing, monitoring and evaluating the Plan of Correction (POC).
Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Penalty
Summary
A resident with diagnoses of depression, anxiety, and borderline personality disorder was identified as being a danger to self and others (DTSO) after verbalizing intentions to harm self and others. Despite a physician's order for transfer to a general acute care hospital (GACH) and recommendations for psychiatric and psychological consultations, the resident refused these interventions. The facility failed to implement 1:1 sitter observation, did not monitor or document the resident's behavior after being identified as DTSO, and did not develop or implement a care plan to address the resident's refusal of transfer or psychiatric consultation. There was no evidence in the medical record that the facility monitored the resident's behavior or provided additional interventions after the resident refused psychiatric consultation. Staff interviews confirmed that no hourly monitoring, documentation, or care planning was initiated following the resident's refusal of transfer and ongoing verbalizations of self-harm or harm to others. The interdisciplinary care team did not meet to address the situation, and there was no documentation of behavioral observations or safety interventions in the resident's chart during the period of risk. As a result of these failures, the resident was later found unresponsive in their room with opened prescription medication containers not dispensed by the facility. The resident was transferred to the hospital via emergency services, where toxicology confirmed an intentional overdose of tricyclic antidepressants. The resident required intubation and admission to the intensive care unit. The facility's lack of assessment, supervision, monitoring, and care planning for a resident identified as DTSO directly preceded this critical incident.
Removal Plan
- The charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist.
- If a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior, and refused to be transferred to the hospital licensed nurse will immediately notify MD.
- The Director of Social Services completed a Psychosocial Assessment of identified residents who has a diagnosis of depression, reviewed and updated Care Plan as necessary.
- Licensed staff were instructed to document behavioral observations in the monitoring log such as DTSO every hour and notify the nurse or RN supervisor and/or designee.
- The Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.
- The Director of Social Services completed a psychosocial assessment of all residents with a diagnosis of depression to identify residents who may be DTSO and no other residents were identified at risk of harming themselves or others.
- Situation, Background, Assessment, and Recommendation (SBAR) / Change in Condition (COC) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status.
- 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.
- The care plan was reviewed and updated for identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.
- The Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety.
- Crisis Intervention Plan included: Provide safe and clean environment; Visual check and document monitoring of resident behavior every hour for resident safety; Administer medication as ordered; Diet as ordered; Encourage to verbalize feelings; Always approach in calm and friendly manner and unhurriedly; To ensure all needs are met; Provide emotional support; Maintain comfort and dignity; To call doctor of medicine (M.D) for any noted change of condition.
- Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD.
- Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation.
- Behavioral and Crisis intervention care plan will be implemented to reflect ongoing risk for harm to self and others. Interventions included: PRN and scheduled psychiatric medication management; Behavior tracking and psychiatric consultation follow-up; Staff re-education on management of residents with psychosocial adjustment difficulties; Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques.
- The ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.
- Licensed staff in-services will continue until compliance is met.
- All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant regarding the existing policies and procedures: Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others; Requesting, Refusing and/or Discontinuing Care or Treatment; Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy.
- The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months.
- All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician.
- Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Secure Rehab Equipment Leads to Resident-to-Resident Assaults
Penalty
Summary
The facility failed to ensure that the rehabilitation (Rehab) room and its equipment were secured and supervised at all times, resulting in unauthorized access by residents. Specifically, a resident with a history of anxiety disorder, cognitive decline following a stroke, and intact cognition according to the Minimum Data Set (MDS), was able to enter the Rehab room without staff knowledge and obtain a dowel, a piece of equipment used for physical therapy. The Rehab room door was routinely closed but not locked when staff were not present, and weighted dowels and free weights were left unsecured and accessible on the wall. This lack of supervision and security allowed the resident to use the dowel to physically assault two other residents on separate occasions. In one incident, a resident was struck on the left arm, and in another, a resident was hit on the right arm, right shoulder, and face, then pushed to the floor, resulting in a non-displaced fracture of the mid sacrum. Staff interviews and progress notes confirmed that the dowel used in the assaults was taken from the Rehab room, and that staff were unaware of the resident's access to the equipment until after the incidents occurred. Observations conducted nearly three weeks after the second incident revealed that the Rehab room equipment remained unsecured. The facility's policy required individualized safety assessments and targeted interventions to reduce accident hazards, including appropriate supervision based on residents' needs and environmental risks. However, the interdisciplinary care team did not identify or address the risk of residents accessing Rehab equipment unsupervised, nor did they implement interventions to prevent such access. The failure to secure the Rehab room and its equipment, combined with insufficient supervision and lack of timely care plan updates, directly led to the incidents of resident-to-resident physical aggression and injury.
Removal Plan
- Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation completed and submitted. Resident 1 and Resident 3 were immediately separated from each other.
- Resident 3 was transferred to another room in a different wing with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital for assessment and returned the same day. Resident 3's care plan was updated to include a resident-to-resident altercation.
- Resident 1's care plan for behaviors was reviewed and updated to include physical aggressive behavior. Resident 1 was referred to a psychiatric mental health Nurse Practitioner but refused. The IDT met with Resident 1 and her family to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent to GACH for in-patient psychiatric evaluation and returned with a UTI diagnosis and antibiotics. Resident 1's care plan and IDT note was updated to address Resident 1's use of a dowel during the episode of aggressive behavior.
- A tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process.
- The Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created to document and verify daily compliance with this security measure.
- The Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside.
- The IDT was in-serviced by the Senior Nurse Executive to review how to conduct an IDT meeting when reviewing resident to resident incidents.
- An ad hoc QAPI Committee meeting was scheduled to conduct a root cause analysis to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions.
- The Executive Director will oversee corrective actions initiated and monthly thereafter during QAPI meetings, based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits and safety equipment monitoring of rehab equipment random audits, will be reviewed and revised with the QAPI Committee.
- Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
- Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse will perform specific roles in monitoring, oversight, education, compliance, and corrective action implementation.
- All residents were identified as potentially affected by the deficient practice.
- The Interdisciplinary Team (IDT) in-service by the Senior Nurse Executive to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents.
- A log was created to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. The Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- The Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved.
- Inservice training for staff license nurses was started on updating comprehensive care plans for residents that have been identified with physical aggression. The facility will continue training until all staff nurses have attended.
- Inservice training for IDT was started on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. Training will continue until all IDT members have attended.
- Inservice training for rehab staff was started on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on how to track and sign equipment in and out, noting its location and assigned user. Training will continue until all Rehab staff have attended.
Failure to Notify Physician of Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to promptly notify a resident's physician of significant changes in the resident's condition, despite clear symptoms and facility policies requiring such notification. The resident, who had a history of constipation and was at risk due to medication use and decreased mobility, experienced abdominal distension, firmness, and pain, and had not had a bowel movement for two days. Although the nursing staff assessed the resident and noted these symptoms, they did not communicate the full extent of the findings—including abdominal distension, firmness, and pain—to the physician. Instead, only the complaint of constipation was relayed, and the physician ordered magnesium citrate. After administration of magnesium citrate, the resident's symptoms did not improve. The resident continued to experience abdominal distension, firmness, and developed shortness of breath requiring increased supplemental oxygen. The resident also reported severe abdominal pain rated 8 out of 10. Despite these worsening symptoms and the lack of response to treatment, the nursing staff did not notify the physician of the resident's deteriorating condition. Instead, communication remained within the nursing team, and the physician was not informed of the new or worsening symptoms, nor was the resident transferred for higher-level care. Ultimately, the resident was found unresponsive with coffee ground emesis, was not breathing, and had no pulse. Emergency services were called, and resuscitation efforts were unsuccessful. The physician later confirmed that, had they been notified of the full clinical picture, additional interventions such as diagnostic imaging or hospital transfer would have been considered. The failure to notify the physician of the resident's change in condition was identified as a deficiency by the survey agency, as it prevented timely medical intervention and contributed to the resident's rapid decline and death.
Removal Plan
- An in-service was initiated by the DON and the Assistant DON to all licensed nursing staff (all RNs and LVNs) on contacting the physician as soon as possible for any resident's COCs specifically for residents with constipation, abdominal pain, abdominal distention, and abdominal firmness; contacting the resident's physician as soon as possible when there is a delay in medication and when a resident's symptoms do not improve or worsen during a COC; ensuring accurate, complete, and timely documentation; completing an accurate assessment of the residents' overall condition and thorough documentation.
- The DON provided an in-service to direct care staff including nursing assistants in recognizing subtle but significant changes in the resident condition and how to communicate these changes to the LNs. CNAs were re-educated and encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the residents' condition.
- The medical records team conducted an audit of change in a resident's condition or status with emphasis on timely physician notification. The audit results showed residents were identified as not having a BM for three days.
- The facility identified residents who had no BM for three days, the residents were assessed by assigned LNs and the steps stated below were followed. The audit results are reviewed by the RN Supervisor to ensure: any changes to the residents' condition are communicated to the primary physician for any recommendations and for new orders; the nursing team has documented in the residents' medical record relative to changes in the residents' medical/mental condition or status; the residents' CP is updated to reflect the residents' COCs; the licensed nursing staff documents in the residents' clinical record for the COC reported or assessed by licensed nursing staff; the RN Supervisor has validated the completion of the SBAR by LNs.
- The DON and Regional Clinical Consultant initiated Competency Skill Checks for all RNs on COCs, notification of physicians, changes/worsening conditions, specific system assessment with emphasis on bowel management, Point Click Care clinical alert and hand-off communication. Competency Skill Checks will be completed for any RN currently on medical leave or vacation before providing patient care. In-services will be continued by the DON until all licensed staff are re-educated.
- The facility has created a bowel management tool for significant COCs identifying the need to notify the physician. LNs are responsible for identifying significant COCs on bowel management: License nurses will identify Residents who have not had BMs for 72 hours, with new or worsening symptoms, and other associated abnormal changes but not limited to frequency and consistency of bowel, abdominal pain, abdominal distension, decreased peristalsis, and signs of GI bleeding; upon identification LNs will utilize the tool and document the notification of the physician; LNs will continue documenting the COCs through the SBAR in the clinical health records; LNs will obtain recommendations from the physicians and will carry the recommendations out; the tool will be completed daily during each shift by the charge nurses, the tool will be collected by medical record staff and retained for review.
- The medical records team also conducted an audit of the alert system in PCC. The PCC alert notifies the nursing team when a resident does not have BMs for 24 hours or more.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when a facility failed to ensure a safe and appropriate discharge for a resident with a complex medical and psychiatric history, including epilepsy, encephalopathy, anxiety disorder, and schizophrenia. The resident had fluctuating capacity to make medical decisions, was at risk for falls, and required assistance with ambulation, medication management, and activities of daily living. Despite these needs, the resident was discharged to an unlicensed board and care (B&C) facility that could not provide the necessary level of care, including ambulation assistance, epilepsy management, or medication administration and storage. The facility did not follow its own discharge and transfer policy and procedures, as the interdisciplinary team (IDT) did not conduct a discharge planning meeting prior to the resident's transfer. Key departments, including nursing, activities, and rehabilitation, were not notified or involved in the discharge planning process. The resident's care plan, which required coordination with rehabilitative therapies and community resources, was not implemented, and the discharge planning review form was incomplete. The facility also failed to verify the B&C's license, assess the appropriateness of the discharge location, or provide a hand-off report to the receiving facility regarding the resident's medical conditions and care needs. As a result of these failures, the resident experienced a series of adverse events after discharge, including a fall with head injury at the B&C, subsequent hospitalization, transfer between multiple facilities, and an episode of elopement that led to police intervention and further hospitalization. Interviews with facility staff and external providers confirmed that the resident's needs exceeded the capabilities of the B&C, and that critical steps in the discharge process, such as medication reconciliation, communication with the receiving facility, and post-discharge follow-up, were not performed.
Removal Plan
- The Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility's Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members.
- The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act).
- The Social Services consultant worked 1:1 with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes.
- The facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident's medical history and medication reconciliation was provided to receiving facility. No similar issues were identified.
- For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility's SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness.
- For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness.
- Discharge planning will begin on the residents' admission to the facility.
- The Attending Physician and the IDT will review the residents' progress and determine a possible discharge date and document in resident's health record.
- The facility Admin notified Resident 1's attending physician, by phone of the concerns related to the resident's transfer to the Board and Care, the fall sustained and readmission to the hospital.
- The facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct.
- The facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents.
- The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident.
- The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident's health record.
- The facility will ensure that the resident receives adequate follow-up including the ability to have a physician's prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident's ordered medications and discharge instructions to the receiving facility and documented on the resident's health record.
- The facility's SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well.
- The facility's SSD/Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward.
- Newly hired licensed nurses/IDT will be educated by the facility's DON/DSD on facility's P&P pertaining to Discharge and Transfer of residents during their orientation and as needed.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, who was assessed as being at risk for elopement, was able to leave the facility's secured unit unsupervised. The resident's care plan required staff to conduct visual checks every 15 minutes and to follow specific protocols to prevent elopement. On the day of the incident, a CNA exited the secured unit without ensuring the door was closed and locked behind them, and did not confirm that no residents were following. Surveillance footage showed the resident holding the door open after the CNA exited, then proceeding through the lobby and out the facility's main entrance, which was neither locked nor alarmed at the time. No staff were present in the lobby to monitor the exit. The resident's whereabouts were not documented in the 15-minute monitoring log for several hours, and the assigned CNA later stated that it was unrealistic to monitor and document all assigned residents every 15 minutes due to workload. The facility's receptionist was not present at the front desk during the time of the elopement, and the main entrance door was not secured or alarmed, allowing the resident to exit undetected. The resident was not discovered missing until later in the evening, after which a search was initiated. The resident had a history of exit-seeking behaviors, including wandering, expressing a desire to leave, and packing belongings. Medical records indicated diagnoses such as paranoid schizophrenia, anxiety disorder, epilepsy, and diabetes mellitus, and the resident required regular medication and supervision. The facility's policies required regular checks and supervision for residents at risk of wandering or elopement, but these protocols were not followed, resulting in the resident's unsupervised exit from the secured unit and the facility.
Removal Plan
- The DON provided a verbal one-on-one in-service via phone regarding the elopement policy to CNA 6, following a disciplinary Performance Correction.
- The Registered Nurse Supervisor contacted nearby hospitals and the local police department to locate Resident 3. The ADM contacted private investigators who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI.
- The local police found Resident 3 and dropped Resident 3 off at Clinic 1. The DON communicated with Clinic 1's Nurse who confirmed Resident 3 was currently in Clinic 1 with stable vital signs. The DON notified Resident 3's Primary Physician/Medical Doctor who instructed to transfer Resident 3 back to the facility.
- Two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility.
- The Registered Nurse Supervisor conducted a comprehensive assessment of Resident 3 upon Resident 3's return to the facility. Resident 3's vital signs were stable, no signs or symptoms of major injury were noted. The Medical Doctor ordered to transfer Resident 3 to a General Acute Care Hospital for further evaluation. Facility staff notified Resident 3's conservator regarding Resident 3 was found.
- The DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education.
- The facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.
- The DON and the Director of Staff Development provided in-services to staff members regarding the elopement policy, covering the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- Elopement Trainings: RNs, LVNs, CNAs, department managers and assistants, activity assistants, housekeeping and laundry employees, and dietary service staff received the in-service training for elopement. Staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. Staff not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return.
- The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted in developing the IJ removal plan.
- The facility also installed a new door keypad for safety in the front lobby.
- There were residents residing in the secured unit.
- The ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified.
- The maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted.
- The DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or exiting the secured unit, staff members must check/confirm that no residents are exiting the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
- The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement.
- The facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision.
- The DON, the DSD or the Registered Nurse Supervisor would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log.
- The ADM and the DON developed a Quality Assurance and Performance Improvement for elopement to address the deficient practice in the IJ findings.
Failure to Prevent Elopement and Provide Supervision Results in Resident Injury
Penalty
Summary
A facility failed to provide adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease and dementia and was assessed as lacking capacity for decision-making, had a documented history of wandering and previous attempts to leave the facility without informing staff. The resident's care plan specifically identified the risk for elopement and included interventions such as anticipating needs, encouraging activity participation, and frequent visual checks for safety. Despite these documented risks and interventions, the resident was left unsupervised in a wheelchair in the hallway after being assisted to the restroom, and staff did not maintain the required level of monitoring. On the day of the incident, the resident was observed propelling herself down the hallway and was later seen in the front lobby. The facility's front exit door was left wide open and unmonitored when the receptionist left her post unattended to use the restroom. No staff were present to observe or redirect the resident, and the door alarm was not responded to in a timely manner. The resident exited the facility unsupervised, traveled to an adjacent property, and fell from her wheelchair onto the street. The incident was not immediately noticed by staff, and the resident was found by a passerby who called emergency services. As a result of the elopement and fall, the resident sustained multiple injuries, including fractures to the nose, jaw, and ribs, a laceration to the lip, a hematoma, and damage to dental implants. Interviews with staff and review of records confirmed that the facility did not follow its own policies and procedures regarding supervision, elopement prevention, and door monitoring. The lack of supervision and failure to ensure the function and monitoring of exit doors directly led to the resident's elopement and subsequent injuries.
Removal Plan
- Resident 1 was placed on 1:1 supervision with staff educated on supervision until a safe plan is determined by the IDT.
- In-service education was provided to the weekend and evening receptionist regarding not leaving their post unattended.
- In-service education regarding monitoring/supervision, wandering, and elopement policy was provided to the receptionist and facility staff on shift, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel.
- Facility doors were checked for appropriate function by the Maintenance Director.
- A head count of all in-house residents was initiated and all residents were accounted for.
- Elopement assessments were completed on all residents by the DON/designee.
- Two residents identified at risk for elopement were reviewed by the DON/designee for appropriate care plan interventions.
- In-service education regarding wandering and elopement was provided to facility staff, including licensed nurses, CNAs, therapists, environmental services, social services, activities, dietary services, and administrative personnel. Staff on leave or PRN will be in-serviced on their next scheduled shift.
- An IDT meeting was conducted for the two residents identified as at risk for elopement.
- The DON or designee will audit new admissions with elopement risks and ensure appropriate interventions are in place.
- The SSD or designee will review all new admissions to ensure an elopement risk assessment has been completed, and those residents identified at risk are updated in the Elopement binder. Audits will be conducted until substantial compliance is achieved.
- New hires will receive education on wandering, elopement, and resident safety by the DON, SSD, or designee(s) upon hire and annually thereafter. Ongoing in-service trainings regarding wandering, elopement, resident safety, and resident monitoring/supervision will be performed.
- Elopement risk binders were reviewed and updated by the DON and Administrator. Binders are available at each nursing station and reception area, updated by the SSD with oversight by the DON.
- Elopement code drills were initiated on all shifts and will continue by Administrator/DON and/or DSD.
- A check of facility doors and alarms was performed by the Maintenance Department to ensure function and securement. Frequency increased.
- A check of facility doors and alarms will be performed by the Maintenance Department until substantial compliance is achieved. Any findings will be corrected immediately and trends reported to the QA/QAPI Committee.
- The QAPI Committee will review and discuss elopement and supervision for all residents during QAPI meetings to determine effectiveness and provide feedback and program modification until compliance is maintained.
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