Litchford Falls Health And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent the development and worsening of multiple pressure sores for a resident with significant medical comorbidities and recent spinal surgery. The resident was admitted after a complicated hospitalization that included spinal decompression surgery, epidural hematoma, sepsis, and multiple chronic conditions such as COPD, diabetes, hypertension, obesity, neuropathy, and a history of alcoholism and drug use. On admission, the resident was identified as at risk for pressure sores and for weight loss/malnutrition, with an albumin of 3.5 and an admission weight of 226 pounds, down from 240 pounds at hospital discharge. Early documentation by the facility Wound Nurse misidentified the anatomical site of moisture-associated skin damage (MASD) and an open area, charting it as the right buttock when it was actually on the left, and subsequent orders and NP documentation continued to reference incorrect or inconsistent anatomical locations. As the stay progressed, the resident developed multiple pressure sores to the buttocks, sacrum/coccyx, and gluteal folds. There were repeated inconsistencies and gaps between wound assessments and the entry of corresponding treatment orders. On 11/3, a Stage II buttock pressure sore was documented and treated with collagen and a border gauze, but the site was again mis-labeled as the right buttock when the Wound Nurse later stated it was on the left. On 11/10, the Wound Nurse documented four pressure sore sites, including non‑stageable areas and a Stage II right buttock wound, but no new treatment orders were entered that day, and the November TAR showed only collagen treatment to the right buttock on 11/10 and 11/11. The Wound Nurse stated she would have used facility wound protocols on 11/10 and 11/11 but did not document this, and acknowledged that without orders, other nurses would not know the treatment plan. On 11/12, the Wound Nurse documented necrotic tissue, foul odor, and multiple pressure areas, while the Wound NP’s note the same day described several new unstageable wounds but did not mention the coccyx/sacrum wound or foul odor, and wound numbering and locations were inconsistent with prior documentation. The facility also failed to timely and consistently address the resident’s nutritional status and significant weight loss in relation to wound development and healing. The RD first recommended Med Plus 1.7 on 10/31 due to intake not consistently meeting estimated needs, but no physician order for this supplement was entered in October or November. The resident experienced a substantial weight loss from 226 pounds on admission to 197.2 pounds by mid‑November, with a drop in albumin from 3.5 to 3.0, and one weekly weight was missed. The RD did not document further follow‑up until 12/8, at which time a more than 30‑pound weight loss over two months and three pressure sores were noted, and supplements including Med Plus, multivitamin, vitamin C, and zinc were again recommended; these were not started until 12/10. After hospitalization for a worsening left‑sided sacral/buttock ulcer requiring sharp debridement and initiation of negative pressure wound therapy (wound vac), the resident returned to the facility on 12/5 with orders to resume wound vac therapy as soon as possible and to use a low air loss bed, strict turning, and activity restrictions. No pressure sore treatment orders were entered into the electronic record until 12/8, and there were no documented wound treatments on 12/6 and 12/7. A nurse who cared for the resident that weekend reported not knowing where to obtain a wound vac and believing it had to be specifically ordered, so she applied wet‑to‑dry dressings instead. The DON stated a wound vac was available in the treatment room and that multiple nurses were trained to apply it, and she had not been notified that staff could not locate or use it. When the Wound Nurse returned on 12/8, she found no wound orders in the system and no wound vac in place, only a clean wet‑to‑dry dressing, and then initiated wound vac and dressing orders. Throughout the stay, the care plan and documentation were updated intermittently, but the report describes failures in accurate wound site identification, timely order entry, consistent implementation of wound vac therapy, and systematic evaluation of the resident’s nutritional decline in relation to the development and worsening of multiple pressure sores.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate nutrition and monitoring for a resident with complex medical needs, including not initiating an RD-recommended supplement, not obtaining weekly admission weights per facility practice, and not evaluating significant weight loss and declining albumin. The resident was admitted after a complicated hospitalization that included spinal decompression surgery, an epidural hematoma requiring additional surgery, sepsis from hospital-acquired pneumonia, and multiple chronic conditions such as COPD, diabetes, hypertension, obesity, osteoarthritis, neuropathy, and a history of alcoholism and illegal drug use. The hospital discharge summary documented a last hospital weight of 240 pounds 4.8 ounces, while the facility admission weight on the same date was 226 pounds. On admission, the resident’s albumin was 3.5, within normal limits, and the care plan identified risk for weight loss or malnutrition related to recent acute illness, hospitalization, and chronic disease, with interventions including RD consult as needed, recording meal intake percentages, reviewing dietary preferences, and providing a therapeutic diet as ordered. On 10/31/25, the RD assessed the resident and documented that he had MASD to the buttocks, was on a diabetic diet, and was consuming 50–75% of his meals. The RD noted that his intake did not appear to consistently meet his estimated nutritional needs and recommended Med Plus 1.7, 90 ml twice daily with medications. However, review of physician orders for October and November showed that Med Plus was not ordered following this recommendation, and the RD later stated she did not know why nutritional support had not started at that time. The DON reported that residents were to be weighed weekly for four weeks after admission and then placed on an individualized schedule, and that the RD typically reviewed any abnormal weights. Nurse #1, who helped oversee weekly weights, reported that the facility missed weighing the resident during the first four weeks after admission as required by their system, and that the first weight she could find after admission was 197.2 pounds on 11/14/25, reflecting a significant loss from the 226-pound admission weight. This weight was not entered into the electronic record, and there was no documented assessment or follow-up of the weight loss at that time. During this same period, the resident’s skin condition worsened. On 10/24/25, the Wound Nurse documented MASD and an open area on the right buttock. By 11/10/25, the Wound Nurse documented four pressure sores, three unstageable and one Stage II, including one described as black and bleeding. On 11/12/25, the Wound Nurse documented multiple pressure sores, one necrotic with foul odor, and noted that the Wound NP planned to order labs. Labs on 11/13/25 showed the resident’s albumin had dropped to 3.0, an abnormally low level and a 0.5 decrease from 10/24/25. There was no documentation from 11/14/25 through 11/24/25 of an assessment of what was contributing to the resident’s weight loss and low albumin or of possible interventions. The RD did not evaluate the resident again until 12/8/25, after a hospitalization for worsening pressure sores and readmission on 12/5/25, at which time she documented that the resident had lost more than 30 pounds in two months, had three pressure sores present on admission, and had increased nutritional needs for wound healing. She again recommended Med Plus 1.7 and additional supplements, which were ordered and started on 12/10/25, marking the first time the Med Plus order appeared on the MAR since her initial recommendation on 10/31/25. Throughout this period, there was no documentation that weight loss or nutritional concerns were discussed at the 11/12/25 care conference, and key staff, including the MDS nurse, were not familiar with the resident’s weight loss or related interventions, contributing to the failure to timely address the resident’s nutritional decline. The deficiency also includes the facility’s failure to obtain admission weights per its stated system for another newly admitted resident, which prevented establishment of individualized weight monitoring timeframes. The DON stated that residents were to be weighed weekly for four weeks after admission, with the first four weights used to determine future monitoring schedules, and that Nurse #1 helped oversee weekly weights. However, Nurse #1 reported that the facility had missed weighing the resident during the first four weeks following initial admission, and that the 11/14/25 weight was the first weight she could locate after the 10/23/25 admission weight. This gap in weight monitoring, combined with the failure to act on the RD’s supplement recommendation and the lack of documented evaluation of significant weight loss and declining albumin, formed the basis of the cited deficiency for failure to provide sufficient food and fluids to maintain the resident’s health.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident experiencing a change in condition and for wound documentation. The resident was transferred to the hospital for altered mental status. On the date of transfer, Nurse #2 completed a transfer form and an SBAR form that were dated for that day but contained vital signs from the previous day. The SBAR form also had a designated area for additional nursing notes about the change in condition, which was left blank. Review of the medical record showed no narrative progress note documenting vital signs at the time the altered mental status was first observed. In interview, Nurse #2 stated she and the facility Wound Nurse noticed the resident was not responding at baseline, that she took the resident’s blood pressure and pulse, and that the resident was not having labored breathing, but she did not remember the vital sign values and did not enter them into the record, stating she had written them on a piece of paper that was later lost. The DON confirmed that the vital signs taken at the time of the altered mental status were not entered into the electronic medical record, leaving the record incomplete. The deficiency also includes inaccurate wound documentation for the same resident. On an admission skin observation assessment form, the facility Wound Nurse documented an open area on the right buttock. Later, on a skin assessment form, the Wound Nurse documented that the resident was seen by the Wound NP for a pressure sore to the right buttock, and the Wound NP documented a Stage II pressure sore to the right buttock. In a subsequent interview, the facility Wound Nurse confirmed that she had not documented the correct location of the open area on the initial skin observation assessment and that both she and the Wound NP had inaccurately documented the wound as being on the right buttock for several weeks when it was actually on the left buttock. The DON, present during the interview, stated that both the Wound Nurse and the Wound NP were newer to their roles, which may have contributed to the inaccurate documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in five out of seven resident rooms on one hall. Specific deficiencies included broken and dirty PTAC (heating and air conditioning) units, missing filters, units detached from the wall, and visible debris such as rubber bands and unidentified substances inside the units. Additionally, there were damaged floor tiles, dirty baseboards and flooring, and a broken electrical outlet cover. These issues were directly observed during a tour with the Maintenance Director, who acknowledged the need for repairs and cleaning in the affected areas. Interviews with the Maintenance Director and Housekeeping Director revealed that responsibilities for cleaning and maintenance were divided between their departments, with housekeeping cleaning the outside of PTAC units and maintenance handling the inside. Despite daily cleaning routines described by the Housekeeping Director, the observed deficiencies indicated that these routines were not effectively ensuring cleanliness and repair in the resident rooms. The Administrator confirmed expectations for cleanliness and equipment maintenance, but the observed conditions did not meet these standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident, the facility did not complete a Discharge MDS assessment upon the resident's discharge home with a family member, as confirmed by both the MDS Coordinator and the Administrator, who acknowledged the assessment was missed due to oversight. Review of the resident's records showed no Discharge MDS was present, despite the requirement to complete one at the time of discharge. For another resident with a history of non-Alzheimer's dementia and neurogenic bladder requiring a suprapubic catheter, the facility did not accurately document the administration of an intravenous antibiotic (ertapenem) in the MDS assessment. The resident received the antibiotic as ordered during the 7-day look back period, as evidenced by the Medication Administration Record (MAR), but the MDS did not reflect this. This omission was confirmed during interviews with the MDS Nurse and Regional MDS Nurse, who agreed the assessment should have indicated antibiotic use during the specified period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately care plan interventions related to smoking for a resident with a history of respiratory failure who was identified as an independent smoker. The resident's most recent Smoking Safety Screen indicated both that he could smoke independently and that he required supervision, creating conflicting information. The care plan included interventions stating the resident may smoke independently, required a smoking assessment as needed, and required supervision with smoking, but these interventions were not consistent with each other or with the resident's actual practice. Observations and interviews confirmed that the resident regularly smoked unsupervised and considered himself an independent smoker. Facility staff, including the Unit Manager and MDS nurses, acknowledged the inconsistency between the care plan and the resident's actual smoking status. The MDS nurses agreed that the care plan should clearly indicate whether the resident was a safe, independent smoker or required supervision, but at the time of the survey, the care plan remained inaccurate.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the 100 [NAME] medication cart was not maintained in a clean and sanitary condition. Specifically, the second drawer of the cart contained red, clear, and white dried substances, as well as pink and white powder. Additionally, six loose, partially dissolved white pills were found at the bottom of the same drawer. During interviews, the Unit Manager acknowledged that nurses were expected to keep medication carts clean and to dispose of loose pills. The DON stated that nursing staff were responsible for maintaining medication carts according to safety and regulatory standards, with unit managers expected to monitor compliance. The Administrator confirmed that the DON was responsible for ensuring that staff maintained medication carts and areas in accordance with safety and regulatory requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a dependent resident with non-Alzheimer's dementia and bilateral hand contractures did not receive routine fingernail care and was not shaved according to his stated preference. The resident was totally dependent on staff for bathing and personal hygiene, as documented in his care plan and most recent MDS assessment. Observations revealed that the resident's fingernails were approximately 1/2 inch long, discolored, and had a dark substance underneath. The resident also had facial hair about 1/2 inch long, despite expressing a preference to be clean shaven. The resident did not exhibit behaviors or reject care. Interviews with staff indicated confusion regarding responsibility for fingernail care and shaving. The activities staff member, prompted by a family request, ultimately trimmed the resident's fingernails, describing them as very long and dirty. The nurse aide assigned to the resident was unsure if she was permitted to trim fingernails and believed shaving male residents was the responsibility of the facility's Scheduler, who only shaved residents when cutting their hair. The Administrator confirmed that staff were expected to provide grooming care according to resident preferences, including fingernail care and shaving, typically on bath days and as needed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's advance directive not to be resuscitated upon her death. The resident, who had multiple diagnoses including stroke, respiratory failure, and congestive heart failure, was admitted with a Do Not Resuscitate (DNR) order. Despite this, when the resident was found unresponsive, a code blue was called, and chest compressions were initiated by a nurse who was unaware of the resident's DNR status. The resuscitation efforts were stopped only after another nurse checked the resident's records and confirmed the DNR order. The incident revealed a lack of an effective system to ensure that the resident's advance directive was honored. The Director of Nursing and a corporate Nurse Consultant confirmed that the code status should be checked before initiating resuscitation. However, the nurse involved in the incident did not verify the resident's code status before starting chest compressions. This deficiency highlights a failure in the facility's protocol to quickly verify and respect residents' advance directives during emergency situations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician when a resident experienced nausea, vomiting, and decreased urine output following an increase in her diuretic medication. The resident, who had a history of congestive heart failure, stroke, hypertension, diabetes, and other conditions, was on a furosemide regimen that was increased by the physician due to observed swelling. Despite the resident's symptoms of vomiting and decreased urination, which were noted by nurse aides, there was no documentation or physician notification regarding these changes. Interviews with staff revealed that nurse aides observed the resident vomiting brown emesis and having decreased urine output over several days, but this information was not communicated to the physician. The resident's condition was not adequately monitored, and the physician was not informed of the significant changes in the resident's health status. The resident was later found to be clinically dehydrated upon hospital admission, where she was diagnosed with multiple severe conditions, including sepsis and cirrhosis. The resident's physician indicated that had he been informed of the vomiting and decreased urine output, he would have continued the diuretic treatment but with closer monitoring. The resident eventually transitioned to hospice care and passed away due to multiple organ failure. The lack of communication and documentation regarding the resident's symptoms contributed to the deficiency in care provided by the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that labs were drawn as ordered for a resident whose diuretic medication was increased. This oversight occurred despite the resident being at risk for complications due to diuretic use, as noted in her care plan. The lab work, which was ordered to monitor the resident's condition after an increase in furosemide dosage, was not completed because the order was not entered into the lab draw book, leading to a lack of communication with the phlebotomist. Additionally, there was a failure in effective communication between nurse aides and nurses regarding the resident's symptoms of vomiting and decreased urine output. The resident experienced vomiting and a significant decrease in urine output, which were not adequately documented or communicated to the physician. This lack of communication resulted in the resident not receiving nausea medication as prescribed and the physician not being informed of the resident's lower urine output after the diuretic dosage was increased. The resident, who had multiple chronic conditions including congestive heart failure, stroke, and diabetes, was eventually referred to hospice care. Despite the resident's transition to hospice, the facility's failure to complete the ordered lab work and communicate critical changes in the resident's condition contributed to a lack of timely medical intervention. The resident was later hospitalized with severe complications, including dehydration, acute kidney injury, and sepsis, and subsequently expired in the hospital.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility staff failed to effectively communicate with the Wound Nurse Practitioner (NP) regarding the care plan for a resident with a pressure sore. The resident, who had a history of stroke, hypertension, diabetes, pelvic fracture, and congestive heart failure, was admitted to the facility and later developed a pressure sore. The Wound NP recommended a specific treatment plan, including cleansing the wound with a wound cleanser, applying silver alginate, and changing the dressing three times per week. However, the facility staff did not update the orders to reflect these recommendations, and the dressing changes continued to be performed daily. The situation worsened when the Wound NP assessed the resident again and noted a significant deterioration in the pressure sore, recommending a new treatment plan involving Dakin's solution for cleansing, Santyl, and calcium alginate, with dressing changes every three days. Despite these recommendations, the facility staff did not follow the updated treatment plan, as the orders were entered incorrectly, omitting the use of Dakin's solution and continuing daily dressing changes. The Facility Wound Nurse misunderstood the instructions, believing that Dakin's and Santyl could not be used together, and did not realize the frequency of dressing changes should have been reduced. The resident's condition continued to decline, with the pressure sore worsening and the resident becoming resistive to care. The Wound NP suspected a terminal condition might be contributing to the rapid deterioration. The resident was eventually transferred to the hospital after a fall, and hospice services were initiated. The lack of adherence to the Wound NP's treatment recommendations and the miscommunication between the facility staff and the Wound NP contributed to the deficiency in care for the resident's pressure sore.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete medical records for a resident who experienced a fall and subsequent injury. The resident, who stayed at the facility from January 27 to February 8, was found on the floor with a hematoma on his head and complained of pain on the morning of February 8. Despite being transferred to the hospital for evaluation, there was no documentation of the fall or any assessment of injuries in the resident's medical record prior to a note made on February 10. This note, made by the Minimum Data Set assessment nurse, mentioned a review by the interdisciplinary team but lacked details about the timing of the fall or the assessment of injuries. Interviews with staff confirmed the absence of proper documentation regarding the circumstances of the fall and the resident's condition following the incident.

Penalty

Inspection fine: $253,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately consult with a resident's Medical Doctor (MD) for order clarification when there was a lapse in the resident's coverage of an oral anticoagulant medication, Eliquis. This medication is crucial for reducing the risk of stroke and blood clots in individuals with atrial fibrillation. The resident, who had a history of strokes, deep vein thrombosis (DVTs), pulmonary embolism (PE), and atrial fibrillation, was admitted to the hospital due to a change in mental status and was diagnosed with an acute middle cerebral artery (MCA) stroke. The lapse in medication coverage occurred because the facility did not clarify with the Vascular consultant or the resident's physician whether Eliquis needed to be continued until the next Vascular consult. The resident had been receiving Eliquis as part of her medication regimen from February 2024 until September 2024. However, after a Vascular consultation on September 27, 2024, the resident's Eliquis was discontinued, and enoxaparin was initiated. Upon returning to the facility, the order to restart Eliquis was transcribed with a start date of September 28, 2024, and an end date of October 28, 2024. The facility did not consult the physician when the Eliquis was discontinued on October 28, 2024, leading to an 11-day lapse in administration until the next Vascular consultation on November 8, 2024. Interviews with facility staff revealed a lack of a set process to address recommendations from outside consultants. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were unaware of the lapse in medication coverage and did not consult the physician when the medication ran out. The resident's Medical Doctor stated that if he had been informed, he would have recommended consulting the Vascular consultant. The lapse in medication coverage was not intentional, but it resulted in the resident being hospitalized with a stroke.

Removal Plan

• 100% audit of all current residents discontinued/stopped medication in the last 30 days by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator to identify any other medication that was discontinued/stopped/ran-out without consultation with an attending physician.
• Facility employees will ensure any changes in medication or treatment, to include discontinuation of medication such as Eliquis, will be reported to the physician prior to the discontinuation to ensure appropriate medical intervention/assessment is implemented.
• Licensed nurse on duty will inform the resident; consult with the resident's physician; and notify the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly.
• The facility's clinical team initiated a process for reviewing clinical documentation for the last 24 hours and physician orders written in the last 24 hours to ensure any needed notification of changes to the physician, and/or responsible party was done in a timely manner.
• 100% education of all licensed nurses to include full time, part time, and as needed licensed nurses will be completed by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Unit Coordinators.
• 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator and/or Admission nurse completed by the Regional Director of Clinical services.

Penalty

Inspection fine: $253,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involved a failure by the consultant pharmacist to urgently report a significant medication irregularity for a resident with a history of strokes, deep vein thrombosis (DVTs), pulmonary embolism (PE), and atrial fibrillation. The resident was prescribed Eliquis, an oral anticoagulant, to reduce the risk of stroke and blood clots. However, after a vascular consultation recommended the continuation of Eliquis, the medication was not administered from the end of October to early December, despite the pharmacist identifying the lapse during a monthly Medication Regimen Review (MRR) on November 13th. The consultant pharmacist identified the omission of Eliquis but failed to notify the facility or the attending physician urgently. The pharmacist's recommendation to restart Eliquis was not communicated to the facility until November 20th, a week after the MRR. This delay in communication resulted in the resident not receiving the anticoagulant for 36 days, leading to the resident being admitted to the hospital with an acute middle cerebral artery (MCA) stroke on December 3rd. Interviews with facility staff, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), revealed that the report from the pharmacist was not timely and did not highlight the urgency of the situation. The facility's medical director and the resident's attending physician both acknowledged the importance of continuing anticoagulant therapy and expressed that the pharmacist should have alerted the facility immediately upon identifying the medication omission.

Removal Plan

• 100% audit of current residents who have had medical appointments to validate any orders/recommendations from the consulting physician were transcribed to the facility electronic health records and implemented as ordered.
• 100% of all consulting pharmacist nursing recommendations and MD recommendations for current residents were audited to identify any other recommendations that were not transcribed/implemented/acted upon correctly in the facility.
• The licensed pharmacist will review each resident drug regimen monthly and report any irregularities to the attending physician and the Director of Nursing to be acted upon in a timely manner.
• The facility's clinical team initiated a process for reviewing pharmacy recommendations completed by the licensed pharmacist to ensure the recommendations to include any irregularities on drug regimen are reported to the attending physician and acted upon in a timely manner.
• 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1, Unit coordinator #2 and/or Admission nurse completed by the facility administrator.
• The facility Administrator conducted a phone Inservice education to the facility medical director, attending physician, and the licensed pharmacist who provide services to the facility on the importance of ensuring any medication irregularity is communicated to the attending physician timely for proper follow through.

Penalty

Inspection fine: $253,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an uninterrupted course of Eliquis, an oral anticoagulant, for a resident with a history of strokes, deep vein thrombosis (DVT), pulmonary embolism (PE), and atrial fibrillation. The medication was discontinued 11 days before the resident's follow-up from an outside vascular consultation, resulting in the resident missing the medication for 36 days until she was discharged to the hospital. This lapse occurred because the facility did not transcribe an order for Eliquis into the resident's electronic medical record (EMR) after her vascular consultation. The resident was admitted to the hospital due to a change in mental status and was diagnosed with an acute middle cerebral artery (MCA) stroke. The facility's failure to transcribe the order for Eliquis after the resident's vascular consultation on 11/8/24 was a significant medication error. The resident's medical history included chronic anticoagulation due to atrial fibrillation and a history of DVT and PE, making the continuation of Eliquis critical. Interviews with facility staff revealed that the process for reviewing and transcribing orders from outside consultations was not consistently followed. The hall nurse was initially responsible for transcribing orders, but the Unit Manager was supposed to ensure the task was completed. However, the consultation paperwork was not always reviewed or followed up on, leading to the oversight in the resident's medication regimen.

Removal Plan

• 100% audit of current residents who have had medical appointments to validate any orders/recommendation from the consulting physician were transcribed to the facility electronic health records and implemented as ordered.
• 100% audit of current residents' medication discontinues to validate any discontinued medication that was done based on the physician orders to ensure such actions are done based on the medical guidance to prevent significant medication error.
• A licensed nurse on duty will review a consultation report for any resident who returned from medical appointment while on duty and transcribe any orders in facility electronic health records.
• Employees will administer medication based on physician orders, to include Eliquis, to treat a specific condition as diagnosed, and document the administration of such medication in each resident's clinical record.
• The facility's clinical team initiated a process for reviewing clinical documentation to include the review of medical appointments ordered and/or scheduled to ensure the appointment is scheduled and take place as ordered.
• 100% education of all current clinical leadership team members to ensure residents' medical appointments are reviewed in the daily clinical meeting to ensure ordered appointments are scheduled, completed, and the consultation forms from the completed appointments are reviewed for any new orders and recommendations.
• Assistant Director of Nursing will provide 100% education of all licensed nurses and Medication aides, to include full time, part time, and as needed nursing employees, on the importance of administering medication per physician order, consulting the attending physician before medication stopped/discontinued, and ensuring consultation forms for residents who returned from the medical appointment are reviewed for any new orders/recommendation.

Penalty

Inspection fine: $253,445

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate the use of compression stockings for a resident with a history of deep vein thrombosis (DVTs), pulmonary embolism (PE), and atrial fibrillation. The resident was admitted to the facility after a hospital stay for a left distal fibular fracture. Despite recommendations from a vascular consultation to use compression stockings daily, this order was not transcribed into the resident's electronic medical record (EMR) upon her return to the facility. Interviews with facility staff revealed that the nurse on duty at the time of the resident's return from the vascular consultation did not recall seeing an order for compression stockings. Subsequent reviews of the resident's physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) confirmed the absence of orders for compression stockings. The resident's care plan and Kardex also did not include instructions for the use of compression stockings, indicating a breakdown in communication and documentation processes. Further interviews with the facility's staff, including the Unit Manager and Assistant Director of Nursing (ADON), highlighted a lack of clarity and follow-through in the process of transcribing and implementing external consultation recommendations. The ADON explained that the nurse should have reviewed the new orders, obtained provider approval, and transcribed the order into the EMR, which did not occur. This oversight resulted in the resident not receiving the recommended compression stockings, which were intended to manage her chronic bilateral lower extremity DVTs.