Recent Health Citations in Maryland

June Edition 2024

Welcome to our specialized update for social workers across Maryland’s LTC facilities. We have carefully compiled some of the latest health deficiencies reported by state surveyors, organized by scope and severity to help you understand and tackle the most pressing challenges in your work environment. This newsletter is designed to support you in your crucial role of safeguarding the well-being of our residents.

This edition includes selected citations related to social work from the newest CMS data release for Maryland, dated 06/26/24. Reports covering 11/20/23 to 06/26/24 were analyzed.

While our AI promptly analyzes new data swiftly after each monthly CMS update, be aware of the time gap between when citations occur and when CMS publishes them, which varies by state and CMS release.

Recent Citations Related to Social Work

Missed Quarterly Care Plan Meetings for Multiple Residents

Scope Severity Level
E
F0657

Cited on 02/28/2024

Short Summary

A complaint survey revealed that the facility did not conduct quarterly care plan meetings for several residents in 2023. These meetings are essential for updating individualized care plans based on residents’ assessments and needs. Medical record reviews and interviews with the DON confirmed the issue, indicating a systemic problem in the care planning process. For instance, one resident had only one care plan meeting throughout the year, missing the scheduled meetings in March, September, and December. This lapse raises concerns about the continuity and quality of care provided, as care plans are crucial for addressing residents’ unique medical and personal needs.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Inaccurate Resident Records and Documentation Discrepancies

Scope Severity Level
E
F0842

Cited on 11/20/2023

Short Summary

The facility experienced issues with maintaining accurate resident records, leading to discrepancies in documentation. For one resident, conflicting information about dental status was found in various assessments. Additionally, incorrect room name displays caused confusion for multiple residents. Another resident faced inadequate documentation and implementation of physician orders, particularly concerning hypoglycemia management and essential care needs like nutritional monitoring and dialysis access. Discharge instructions from hospitalizations were also not promptly addressed or accurately documented, impacting the resident’s care plan.

Corrective Actions

A comprehensive review and update of resident medical records were conducted, a regular audit system was implemented, and correct resident name labels were ensured. Nursing staff received training on Schedule II medication destruction, and an admission resource binder was developed. Licensed nursing staff were educated on accurate documentation and physician orders, and a communication protocol between nursing and dietary staff was established. Regular audits for compliance with controlled substance policies were also conducted.

See CMS Report »

Deficiencies in Medication Administration and Documentation Processes

Scope Severity Level
E
F0658

Cited on 11/20/2023

Short Summary

A survey identified deficiencies in medication administration and documentation processes. One resident with Diabetes Mellitus lacked a sliding scale in their insulin order, potentially affecting blood sugar management. Another resident with end-stage renal disease and dialysis dependence had incomplete documentation on the Dialysis Communication Form, raising concerns about the transfer of vital health information between the facility and the dialysis clinic.

Corrective Actions

Corrective actions include accurate medication transcription and administration, insulin sliding scale parameters, reporting health changes, updating electronic records, consistent narcotic administration, staff education, double-check systems, complete dialysis forms, accurate vital sign monitoring, policy updates, regular audits, and staff training on electronic medical records.

See CMS Report »

Care Plan Development and Review Deficiencies Identified

Scope Severity Level
E
F0657

Cited on 11/20/2023

Short Summary

A facility did not develop a care plan for a resident with chronic respiratory conditions and tobacco use, despite identifying the resident as an unsafe smoker requiring supervision. Additionally, the facility failed to involve the Power of Attorney (POA) in care plan meetings for another resident. Several residents reported not being informed about or invited to care plan meetings, and there was a lack of timely scheduling and documentation of these meetings. The Social Work Director, responsible for planning care plan meetings, could not provide sign-in sheets for some residents, indicating organizational issues in the care planning process.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Qualified Social Worker Staffing Gap Identified

Scope Severity Level
E
F0850

Cited on 11/20/2023

Short Summary

A facility with over 120 beds experienced a 5-month period without a qualified, full-time Social Worker overseeing social service duties. Employee records indicated a staffing gap from March to September 2022, during which individuals without the required qualifications were employed as Social Service Director. The Nursing Home Administrator confirmed the absence of a qualified Social Worker during this time.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Incomplete Medical Records for Wound Care Management

Scope Severity Level
D
F0842

Cited on 03/26/2024

Short Summary

A facility did not maintain complete and accurate medical records for a resident who was readmitted and required daily wound care management with a wound vac. The EMR and TAR did not reflect the physician’s orders. The DON acknowledged that the nurse should have corrected the orders during routine chart checks.

Corrective Actions

Night shift nurses received in-service education on chart checks.

See CMS Report »

Communication Gaps in Pressure Ulcer Preventative Measures

Scope Severity Level
D
F0658

Cited on 03/26/2024

Short Summary

Preventative measures for a resident with an unstageable pressure ulcer on the sacrum were not clearly communicated to all staff responsible for implementation. Physician orders for interventions such as floating bilateral heels, pressure relieving cushion, preventative mattress, and turning/repositioning every 2-3 hours were inconsistently documented. The Wound Nurse Practitioner’s treatment recommendations were not effectively communicated to GNAs. Interviews with an LPN and the DON revealed that GNAs relied on the Kardex, which did not consistently include all prescribed interventions, and limitations in the electronic medical record system hindered proper documentation of GNA tasks.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Care Plan Updates and Quarterly Meetings Deficiency

Scope Severity Level
D
F0657

Cited on 03/26/2024

This citation appears to closely resemble the incident immediately above this one. It is highly probable that both originated from the same event but have been cited under different F-tags. To maintain brevity, we have opted not to show the citation details here.

See CMS Report »

After-Hours Visitor Access Deficiency

Scope Severity Level
D
F0563

Cited on 03/26/2024

Short Summary

A facility was found to lack a system for after-hours visitor access, as highlighted by a complaint involving a spouse unable to admit a resident from the hospital. Despite knocking and calling, the family had to involve the police to gain entry. Surveyors observed the front door locked before business hours and multiple unanswered phone calls. Staff eventually directed the surveyor to an alternative entrance, indicating unclear after-hours access procedures. The DON acknowledged ongoing issues with phone responsiveness and access, despite specific directions for ambulances. Instances of patients arriving with discharge paperwork suggested inconsistencies in access protocols.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Medical Record Maintenance and Resident Information Safeguarding Issues

Scope Severity Level
D
F0842

Cited on 03/05/2024

Short Summary

The facility encountered issues with maintaining medical records and safeguarding resident-identifiable information. An unattended computer screen displaying a resident’s medication profile was left visible on a medication cart in the hallway. Incorrect patient information was scanned into another resident’s electronic medical record, causing discrepancies. Additionally, a resident’s substitute decision maker was incorrectly identified without proper documentation, and the resident’s profile was not updated upon admission. Inconsistent documentation was also found in a skin evaluation, where an open skin area was noted by one nurse but not identified in a subsequent weekly evaluation.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Missed Interdisciplinary Care Plan Meeting for Resident During MDS Assessment

Scope Severity Level
D
F0657

Cited on 03/05/2024

This citation appears to closely resemble the incident immediately above this one. It is highly probable that both originated from the same event but have been cited under different F-tags. To maintain brevity, we have opted not to show the citation details here.

See CMS Report »

Incomplete and Inaccurate Medical Records Identified

Scope Severity Level
D
F0842

Cited on 02/28/2024

Short Summary

During a complaint survey, discrepancies were found in the medical records of a resident who had been discharged to the hospital. Issues included incorrect documentation of medication administration, a sleep snack, and blood pressure readings on the discharge date.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Instances of Disrespect and Lack of Dignity in Resident Care

Scope Severity Level
D
F0550

Cited on 02/28/2024

Short Summary

Facility staff failed to treat residents with respect and dignity in several instances. One resident with an intracranial injury was made to mop his/her own urine by a former staff member, despite lacking decision-making capacity. Another resident reported verbal abuse by a staff member, indicating issues with respectful communication. Additionally, during lunch service, one resident was served significantly later than another, who struggled to eat with his/her fingers until assisted by staff.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Delayed Development of Comprehensive Care Plans for Residents with Mental Health Needs

Scope Severity Level
D
F0656

Cited on 11/20/2023

Short Summary

The facility did not create timely comprehensive care plans for two residents. One resident, admitted with PTSD and adjustment disorder, had a care plan for psychological services developed 10 months post-admission. Despite multiple psychiatric visits, there was a 5-month gap without documented visits, indicating a delay in addressing mental health needs.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Lack of Social Work Assistance for Resident Requesting Discharge

Scope Severity Level
D
F0745

Cited on 11/20/2023

Short Summary

A resident expressed a desire to be discharged home but did not receive social work assessments or discharge planning. The Social Services Director noted the absence of an active social work department upon her arrival, with temporary assistance provided only for discharge planning, not for completing social histories or care plan meetings.

Corrective Actions

We did not find corrective actions in the report.

See CMS Report »

Recent High Scope and Severity Citations

Failure to Address Abuse Allegation Promptly

Scope Severity Level
J
F0600

Cited on 04/12/2024

Short Summary

A cognitively impaired resident reported being physically abused by a staff member, resulting in a bleeding nose. The nursing staff did not inform the DON or Executive Director immediately, and the accused staff member continued working until the next morning. The DON discovered the incident the following day through hospital records. The RN Night Supervisor did not remove the accused staff member, delaying the response to the abuse allegation. Discrepancies in staff accounts and the resident’s behavioral history further complicated the situation, highlighting a deficiency in the facility’s response to abuse allegations.

Corrective Actions

Suspended shifts and placed Agency GNA on Do Not Call List, implemented QAPI plan for CMS abuse procedure adherence, re-educated all nursing staff, and audited abuse complaints for timely reporting.

See CMS Report »