Failure to Prevent Neglect and Respond to Opioid Overdose
Summary
A facility failed to protect a resident from neglect, resulting in the administration of four incorrect doses of morphine sulfate totaling 80 milligrams over a 12-hour period. The resident, who was admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home. The error originated from a transcription mistake during the medication reconciliation process, where three out of five morphine orders were entered incorrectly and the facility's triple check system was not fully completed, lacking a third verification signature. The error was discovered only after a nurse questioned the order, at which point the incorrect order was discontinued and a corrected order was entered. Following the medication error, the resident became lethargic and unresponsive, with unstable vital signs including low blood pressure and oxygen saturation. Despite these changes, there was no documented evidence that the facility provided interventions to reverse the effects of the opioid overdose, such as administering naloxone (Narcan), even after the family inquired about it. Additionally, there was a lack of documented monitoring, assessment, or treatment for the resident's decline after the error was identified. Vital signs and nursing assessments were not consistently recorded, and there was no evidence of physician oversight or coordination with hospice regarding the medication error. Communication failures further contributed to the deficiency. The resident's representative was not notified of the medication error until after the resident's condition had significantly deteriorated. Hospice was not informed of the medication error, and attempts to contact hospice during the resident's decline were unsuccessful due to incorrect contact information. Key facility leadership, including the Director of Nursing and Administrator, were not promptly informed of the incident, and staff interviews revealed a lack of awareness and documentation regarding the resident's condition and the actions taken. The resident ultimately expired without documented evidence of appropriate monitoring or intervention following the overdose.
Removal Plan
- Post Hospice contact information in each nursing unit and include on the face sheet for residents actively on Hospice.
- Make the contact for Community Hospice visible at accessible locations such as a nursing station on each resident unit.
- Ensure that for all residents enrolled in Hospice services, the contact number for Community Hospice is visible and accessible under contacts on the residents' face sheets in both electronic and paper charts.
- Update medication error reporting policy to require the Physician/Nurse Practitioner, upon notification of medication error, to provide direction for monitoring, duration of monitoring, and expected follow up communication.
- Require documentation of the nature of the incident, individuals notified (including family and hospice as applicable), actions taken, orders received, results of continued monitoring, assessments, and communication.
- In-service all on-call Physicians and Nurse Practitioners regarding high-risk medications and review of electronic ordering for safe dosing.
- Educate all nursing staff, including agency staff, by the nursing educator/designee on the updated Medication Error Reporting policy, including directions on provider and family notification as well as resident monitoring and documentation requirements.
- Use education sign-in sheets to document that in-house and agency nurses were educated; educate remaining agency nurses if they return to the facility.
- Compare transcribed orders with original provider order for accuracy; complete and document checks in the paper chart for the next two consecutive shifts.
- Educate all nursing staff (including agency staff) by the nurse educator, supervision, or designee regarding medication reconciliation, medication transcription, triple check, and safe medication administration practices.
- In-service all in-house and agency nurses regarding the abuse/neglect and mistreatment policy, with a special focus on potential neglect related to medication errors and lack of monitoring, assessment, and documentation related to change in condition.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Abuse During Incontinent Care: A CNA was observed on video using forceful and aggressive handling while providing incontinent care to a resident with severe cognitive impairment and total ADL dependence. The resident yelled, moaned, and repeatedly asked what he had done while the CNA grabbed his wrists, turned him forcefully, held him down, and moved his limbs without speaking. Later, the resident told staff and family that a tall man had entered his room, held him down, and hit him, and the CNA admitted he had gotten rough and restrained the resident during care.
A resident with severe cognitive impairment and a history of combative behavior during care was being assisted by two CNAs with incontinence care when the resident became resistive and kicked one CNA in the leg. Instead of following the care plan directive to stop care and return later when the resident was physically abusive, the CNA immediately retaliated by open-handedly slapping the resident hard in the face, causing visible redness and leaving the resident appearing stunned and fearful. The second CNA, who witnessed the slap, briefly left the room to report the incident to the nurse, leaving the resident alone with the CNA who had just abused him, thereby failing to ensure the resident’s immediate protection from further abuse.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
A resident with a history of TBI, anxiety, and mild neurocognitive disorder became agitated after staff moved a wheelchair he had positioned to avoid blocking his window view, leading to escalating verbal aggression toward staff. Witnesses reported that when the resident approached the nurses’ station with clenched fists and swung at an RN, the RN grabbed the resident’s arm and/or shoulder and took him to the floor, then restrained him there until supervisors arrived. Immediately afterward, the resident complained of severe left hip pain, with clinical signs of injury, and hospital evaluation confirmed a left comminuted displaced intertrochanteric fracture requiring surgical repair. Multiple staff later stated that they are not allowed to restrain residents and would instead use de-escalation, walk away, or call for assistance when residents are aggressive, while the DON acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm.
A resident with quadriplegia and intact cognition, care planned and documented as requiring a two-person assist for bed mobility, was being checked by a NA who knew another aide was supposed to assist. The NA rolled the resident toward herself, noted a bowel movement, and turned away to look for supplies while waiting for help, despite the two-person assist requirement. During this time, the resident slid off the bed to the floor. She was initially assessed with only redness to the upper back but complained of increased left leg pain, and was later transferred to the hospital, where she was found to have a left femoral neck fracture. Facility investigation determined the NA failed to follow the care plan and Kardex instructions for two-person bed mobility, and the NHA and DON substantiated neglect during care.
Abuse During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a CNA used forceful and aggressive handling during incontinent care. The resident was a male with severe cognitive impairment, including a BIMS score of 0, and diagnoses that included heart failure, hypertension, end stage renal disease, Alzheimer's disease, stroke, and non-Alzheimer's dementia. He was dependent for ADLs and required assistance from one staff member for care. During the early morning care episode, video footage showed the CNA entering the resident's room, turning on the light, removing the covers, and then grabbing the resident's wrists and forcefully turning him onto his side while removing the brief. The CNA placed his weight on the resident's shoulder, then later pushed the resident to the opposite side, grabbed the resident's wrist again, and forcefully yanked him over while the resident yelled and moaned in distress. The footage also showed the CNA crossing the resident's wrists over his chest, holding him down while adjusting the brief, and grabbing the resident's ankles and moving them toward the center of the bed. Throughout the incident, the CNA did not speak to the resident, and the resident repeatedly asked what he had done. Later that morning, the resident told staff and family that a tall man had entered his room during the night, held him down, and hit him on the face. He said he felt fearful and did not want that man in his room again. Staff who interviewed the resident reported that his account remained consistent, and multiple staff stated the resident had not been combative during care and had not previously made similar allegations. The CNA acknowledged that he had gotten rough with the resident, restrained him while putting on the brief, and admitted he probably should have stopped when the resident was yelling and asking him to stop.
Resident Physically Abused by CNA and Left Unprotected After Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to ensure immediate protection from further abuse once an incident occurred. An elderly male resident with heart failure, unspecified dementia with agitation and other behaviors, and Alzheimer’s disease was admitted to the facility and had a BIMS score of 0, indicating severe cognitive impairment. His care plan documented impaired cognitive function and a history of becoming combative with staff at times, with interventions directing staff not to attempt care when he was physically abusive and to allow time and revisit the task later. Despite these documented needs and interventions, the resident was subjected to physical abuse by a CNA during routine care. On the day of the incident, two CNAs entered the resident’s room to perform routine rounds and provide incontinence care while he was in bed. According to statements and interviews, the resident was awakened, his clothing and brief were removed, and as care proceeded he became resistive and combative. The resident swung and kicked, striking one CNA on the leg. In response, that CNA immediately and open-handedly slapped the resident in the face/forehead. The slap was described by the witnessing CNA as very hard, leaving the left side of the resident’s face a little red and causing the resident to appear stunned, frozen, and nervous, as if afraid to move. The CNA who slapped the resident admitted in her written and verbal statements that she hit him back after he kicked her leg, characterizing it as a reaction. The facility also failed to ensure the resident was protected from further abuse at the time of the incident. After witnessing the slap, the second CNA briefly left the room to notify the nurse, leaving the resident alone with the CNA who had just physically abused him. During this interval, the abusive CNA remained in the room with the resident, and there is no indication that the resident was immediately removed from the abuser or that the abuser was immediately removed from the resident’s presence before the witness left to report the event. This sequence of actions and inactions—failure to follow the resident’s care plan for managing combative behavior, the CNA’s retaliatory slap, and the witness CNA’s decision to leave the resident alone with the abuser—constituted the failure to ensure the resident was free from abuse and protected from further abuse.
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Resident From Physical Abuse Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from physical abuse when a registered nurse (RN) took the resident to the floor during an altercation, resulting in a left comminuted displaced intertrochanteric hip fracture that required surgery. Facility policy on "Abuse: Protection From" stated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property, and that residents must not be subjected to abuse by anyone, including staff. The resident involved had a history of traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance, but was assessed as cognitively intact with a BIMS score of 13. On the evening of the incident, the resident became agitated after staff moved a wheelchair that he had positioned to avoid blocking his window view, and he began yelling and cursing at a nurse aide (NA) about the wheelchair placement. According to multiple staff statements and nursing documentation, the resident paced in his room, continued yelling, and then left the room to go to the bathroom. After several minutes, he approached the nursing station, yelling and threatening the RN, with witnesses reporting that he had his fists clenched and was swinging at the nurse. The RN reported that when the resident swung at him, he grabbed the resident’s arm and/or shoulder and took him down or assisted him to the floor, then restrained him there until supervisors arrived. Witnesses, including NAs and another RN, consistently described the nurse catching the resident’s swing by the forearm or grabbing his shoulder/arm and putting or sitting him down on the floor, after which the resident was observed lying on his right side in front of the elevator, screaming in pain and holding his left hip. Following the takedown, staff observed that the resident complained of 10/10 left hip pain, with the left leg shortened and externally rotated. The resident told staff and later hospital providers that the nurse had “tackled” him to the floor. Hospital records documented that the resident reported being tackled after an altercation about moving a wheelchair to see the sunset, and confirmed a left comminuted displaced intertrochanteric fracture requiring orthopedic surgical intervention. In subsequent staff interviews, multiple nurses and NAs stated that facility practice when a resident exhibits aggressive behavior is to walk away, call for help or a supervisor, attempt de-escalation, remove triggers, and that they are not allowed to restrain residents or hold them to the ground. The Director of Nursing acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm in the form of the hip fracture. The deficiency was cited under multiple Pennsylvania regulatory provisions, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 201.18(b)(1)(3) Management, 201.29(a)(c)(d)(j) Resident Rights, 211.10(c)(d) Resident Care Policies, and 211.12(d)(1)(3) Nursing services. These citations reflect that the resident’s right to be free from abuse and the facility’s obligations regarding resident care policies and nursing services were not upheld in this incident, as evidenced by the RN’s physical handling of the resident that led to a serious injury.
Neglect During Bed Mobility Leading to Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during bed mobility care, resulting in a left femoral neck fracture. The resident had diagnoses including quadriplegia, gastroesophageal reflux disease, and hyperlipidemia, and was assessed as cognitively intact with a BIMS score of 15. The resident’s MDS and care plan documented that she was dependent for mobility and required assistance of two staff for bed mobility. The Kardex and care plan both specified a two-person assist for bed mobility due to her functional limitations. On the day of the incident, a nurse aide entered the resident’s room to check on her and was aware that another aide would be coming shortly to assist. Despite the documented requirement for two-person assistance, the aide rolled the resident toward herself and noted a bowel movement, then turned away to look for a towel or other item to begin care while waiting for help. During this time, the resident slid off the side of the bed and onto the floor. The aide reported that the resident slid off in such a way that there was no way to catch her, and immediately scanned the resident for obvious wounds or bleeding before finding a nurse to perform an assessment. Nursing documentation indicated that the resident was found sitting on the floor, leaning against the nightstand with her legs straight out and her head supported on a pillow against the mattress. Initial assessment noted no visible injuries other than redness to the left upper back, and the resident was assisted back to bed with a Hoyer lift and three staff. The resident complained of increased pain to the left leg, and the physician was notified with orders for x‑rays. Later, the resident was transferred to the hospital for altered mental status, decreasing blood pressure, and increased heart rate, and the hospital reported that she had sustained a left femoral neck fracture. The facility’s investigation concluded that the assigned nurse aide did not follow the Kardex and care plan instructions for required two-person bed mobility assistance, and the allegation of neglect was substantiated by the NHA and DON.
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