Failure to Notify Resident's Representative of Change in Condition During AMA Discharge
Summary
The facility failed to notify a resident's representative of a significant change in condition when the resident, who had a diagnosis of Disorganized Schizophrenia and Psychosis, left the facility Against Medical Advice (AMA). The resident was admitted with a responsible party listed as an advocacy group and was taking antipsychotic medications. Documentation showed that the resident had no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, and was actively involved in discharge planning for a return to the community. On the day of the incident, the resident insisted on leaving the facility, and the physician advised allowing the resident to leave AMA. The resident refused to sign the AMA form, and the responsible party was not present or notified in person. Interviews and record reviews revealed that the Director of Nursing attempted to contact the responsible party by phone several times and left voicemails, but no response was received. The Social Services Director confirmed that the health care proxy should be notified and is the person authorized to sign a resident out AMA, but this did not occur. Facility policy requires notification and documentation of the resident's representative when a resident leaves AMA, but this was not completed as required. The resident's advocate stated they were not informed of the resident's departure and expressed concern for the resident's safety and need for medication.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Penalty
A resident with severe cognitive impairment and a history of falls experienced a fall, but staff failed to notify the family or responsible party as required. Documentation showed that while the MD was notified, no next of kin was listed or contacted, and staff interviews confirmed the lack of family notification despite facility policy.
A resident in an LTC facility was injured during a transfer when she hit her arm on a wheelchair. The CNA did not properly position the wheelchair and failed to report the incident to the nurse, leading to a delay in informing the resident's family and physician. The facility's protocol for reporting and documenting incidents was not followed.
Failure to Notify Family of Change in Resident Condition After Fall
Penalty
Summary
The facility failed to meet licensure requirements regarding the right of residents to be informed of their medical condition and changes in care. Specifically, staff did not notify the family or representative of a resident who experienced a fall. Documentation showed that after the resident was found on the floor, the medical doctor was notified, but there was no next of kin or responsible party listed to be notified, and no progress note indicated that any family notification occurred. The resident involved had a history of impaired gait, lack of coordination, seizures, and severe cognitive impairment. The care plan identified the resident as high risk for falls and included interventions to prevent such incidents. Despite these precautions, the resident experienced a fall, and the facility's policy required both the attending physician and family to be notified after such events. However, the demographic and event records indicated that no responsible party was assigned or notified at the time of the incident. Interviews with facility staff confirmed that the process for notifying family members was not followed in this case. The Admission Coordinator stated that emergency contact information is typically collected prior to admission, and the DON explained that the assigned nurse is responsible for notifying the first contact listed. However, in this instance, there was no documentation of family notification, and the nurse involved was no longer employed at the facility. The facility's policy on falls also required family notification, which was not documented as having occurred.
Plan Of Correction
N0199 Citation: F580 (D/N199-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Due to the date of the incident involving resident #1 (01/23/2023), corrective action for notification could not be accomplished. On 1/24/2023, the Admissions Coordinator updated the demographic sheet to reflect Resident #1's Responsible Party/Emergency Contact. On 6/20/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly to ensure that the resident's responsible party/emergency contact, if any, was notified of the treatment significantly. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents with a responsible party/emergency contact have the potential to be affected by this deficient practice. On 6/23/2025, the demographic sheets for all current residents were reviewed to ensure that the resident's responsible party/emergency contact, if they had one, was listed and the information was accurate. Any problems were corrected. On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 6/23/2025, by Assistant Director of Nursing, all nursing staff, the admissions coordinator, and social services were provided education on the need to identify a resident's responsible party/emergency contact on the demographics sheet, ensure that the contact's information is updated as necessary, and the need to notify the resident's responsible party/emergency contact of any change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly. The Assistant Director of Nursing, or designee, will conduct random audits of demographic sheets for current residents. No less than 10 audits will be completed weekly. Any deficiencies observed will be corrected immediately. The Assistant Director of Nursing, or designee, will review information on a change in condition, to include but not limited to, the resident's physical, mental, or psychosocial status, or the need to alter treatment significantly to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition for all incidents weekly for 2 weeks. Any problems with notification will be promptly resolved. Audits will then be conducted at random for 2 additional weeks of at least 20% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period. Any problems with notification will be promptly resolved. Monthly audits of at least 25% of all incidents of a change in condition related to a resident's physical, mental, or psychosocial status, or the need to alter treatment significantly during that time period will be conducted to ensure that the resident's responsible party/emergency contact, if any, was notified of the change in condition. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Frequency of audits will be determined by the QAPI and QAA Committees. On 6/23/2025, the Admissions Coordinator notified the MDS Coordinator of the need to review the resident's demographics sheet to ensure that the resident's responsible party/emergency contact information, if any, is listed and is accurate during care plan meetings. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. --- practice. On 6/22/2025, Director of Nursing, or designee, observed all medication/treatment carts were locked as appropriate. No other carts were identified to be out of compliance at that time. On 06/18/2025, Assistant Director of Nursing provided education to Staff A on the need to ensure medication/treatment carts are locked when unattended. On 06/18/2025, Assistant Director of Nursing provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 06/18/2025, Assistant Director of Nursing, provided education to all nursing staff on the need to ensure that all medication/treatment carts are to be locked when unattended. The Assistant Director of Nursing, or designee, will conduct random audits of medication/treatment carts. Audits will be no less than 5 audits weekly across all shifts for 3 weeks. Any deficiencies observed will be corrected immediately. No less than 5 audits will be completed monthly thereafter. Frequency of audits will be determined by the QAPI and QAA Committees. Audits will be submitted to the Administrator, or designee, weekly for evaluation of trends and any educational needs. Corrective action(s) will be monitored to ensure the deficient practice will not recur. The findings of audits will be submitted to the Administrator, or designee, to the QA and QAPI Committees monthly for 3 months, then quarterly for 4 quarters. Correction Date: 07/18/2025
Failure to Report Resident Injury
Penalty
Summary
The facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury requiring medical attention for one resident. During an assisted transfer, the resident hit her arm on the wheelchair, and the incident went unreported until a family member identified and reported it to the staff. The resident was observed with a small discoloration under the right eye and scratches on both arms. The resident required substantial assistance for chair/bed-to-chair transfers and had a care plan indicating a risk for falls related to mobility. Despite this, the Certified Nursing Assistant (CNA) did not properly position the wheelchair before transferring the resident, leading to the incident. The CNA failed to report the incident to the nurse, which was a breach of protocol. The Director of Nursing (DON) confirmed that the protocol required staff to report such incidents to the doctor and family, complete an incident report, and document the occurrence. However, there was no documentation related to the incident in the progress notes, and the CNA was reprimanded for not reporting the incident. The facility's policy required all accidents or incidents to be investigated and reported, but this was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers and reporting of incidents on. Resident #1 did not have any negative outcomes related to the alleged deficient practice. Staff B received 1:1 education from the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. Nursing staff was in-serviced by the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident in the facility have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents with change in condition without proper notification of physician and resident's representative. No issues were identified. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. The Director of Nursing/Designee will review all new incidents/changes in condition during the morning meeting to ensure proper notification of resident's representative and physician according to facility policy. **MONITORING:** The Director of Nursing/Designee will conduct daily rounds and chart review x 5 days, then weekly x 4 weeks, then random biweekly review, to ensure that physician and resident's representative are promptly notified of significant changes in condition. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
