Life Care Center Of Lagrange
Inspection history, citations, penalties and survey trends for this long-term care facility in Lagrange, Indiana.
- Location
- 0770 North 075 East, Lagrange, Indiana 46761
- CMS Provider Number
- 155343
- Inspections on file
- 19
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Life Care Center Of Lagrange during CMS and state inspections, most recent first.
Two residents were not afforded adequate privacy and dignity, including one instance where an LPN administered an abdominal injection with the resident’s shirt lifted and the room door open, allowing others in the hallway to see the exposed abdomen, despite facility policy requiring privacy measures during medication administration. Another resident with severe physical and cognitive impairments, totally dependent on staff for dressing, was repeatedly observed in bed visible from the hallway without proper clothing and with the door open and privacy curtain not used, while leadership could not provide documentation or clear rationale for the lack of clothing despite a resident rights policy requiring dignified care.
A resident with gout, bilateral leg pain, depression, PTSD, and dysphagia, and a BIMS score indicating intact cognition, was given a 500 mg acetaminophen tablet and water by an LPN, who then left the room without observing the medication being taken. The resident’s physician order required scheduled administration of acetaminophen for pain but did not authorize self-administration, and record review showed no completed Self-Administration of Medication assessment. Facility policy and the DON’s statements required staff to observe all medication consumption and allowed self-administration only with an appropriate assessment or specific order, but these requirements were not followed, resulting in a deficiency under 410 IAC 3.1-11(a).
Surveyors found that the facility failed to properly notify emergency contacts about the bed-hold policy for two residents who were transferred to the hospital. One cognitively intact resident with chronic kidney disease, diabetes, and a seizure disorder signed a bed-hold notification declining to hold the bed, but the resident’s emergency contact, who was also the durable power of attorney, was not notified when the resident became unresponsive and was sent to the hospital. Another resident with severe cognitive impairment, atrial fibrillation, lumbar fracture, wound dehiscence, and malnutrition was transferred to the hospital, and although the bed-hold policy was sent with EMTs and the emergency contact was informed of the transfer, there was no documentation that the emergency contact was informed of the bed-hold policy, even though the resident signed a form declining bed hold. No written facility policy on bed-hold notification was available for review.
A facility failed to provide necessary oral hygiene for a resident entirely dependent on staff for care. The resident, with severe cognitive impairment and multiple diagnoses, was observed with a dry, coated tongue and dry, caked lips. Despite the care plan and facility policy requiring oral care every 2 to 4 hours, the resident did not receive adequate oral hygiene, as confirmed by an RN.
A facility failed to maintain proper tube feeding for a resident with cerebral palsy and other conditions. The resident's tube feeding supplies were not changed daily as required, with containers dated two days prior. A nurse confirmed the supplies should be changed every 24 hours, per facility policy.
A resident with multiple diagnoses, including diabetes and chronic kidney disease, was administered antibiotics for a UTI without a supporting urinalysis, indicating a medication error. The facility's policy required staff to follow incident policy and performance improvement processes, but the Administrator was unaware of the error.
The facility failed to develop quality improvement plans for recurrent environmental concerns identified in annual surveys. Despite ongoing discussions in QAPI meetings, no formal performance improvement plan was in place, leading to repeated issues with the repair and maintenance of facility floors, walls, and handrails.
The facility failed to ensure a sanitary environment free of hazards on four halls where residents resided or received services. Observations revealed missing finish on handrails, missing baseboards, chipped drywall, and buckled flooring. The Maintenance Director and Executive Director acknowledged the issues but indicated no current plans for repairs.
The facility failed to post daily nurse staffing hours for 3 of 4 days reviewed. Observations showed the posted hours were outdated, and interviews with the DON and Administrator revealed they were unaware of the lapse. Facility policy requires daily posting of nurse staffing data.
Failure to Maintain Resident Privacy and Dignity During Care and While in Bed
Penalty
Summary
The deficiency involves failures to protect resident dignity and privacy by allowing residents' bodies to be exposed and visible from the hallway. In one instance, an LPN administered an abdominal injectable medication to a resident seated in a wheelchair in her room with the door wide open, allowing passersby in the hallway to see her exposed abdomen. Two unidentified residents were observed walking past and glancing into the room during the preparation and administration of the injection. The resident had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, and social phobia, and a recent MDS showed mild cognitive impairment. The facility’s own policy on dose preparation and administration required that privacy rights be observed, including use of privacy curtains to avoid exposure, and the ADON stated that a privacy curtain should be pulled or the door closed when administering abdominal injections. In another instance, a resident with athetoid cerebral palsy, torticollis, spastic quadriplegic cerebral palsy, unidentified intellectual abilities, and aphasia was repeatedly observed from the hallway lying in bed without adequate clothing and with the room door open and privacy curtain not in use. On one observation, the resident had no clothing on and his upper body was naked and exposed; on subsequent observations, he was either wearing only a tee shirt with his lower body loosely covered by a sheet or unclothed with only a sheet covering from the waist down. The resident’s MDS indicated he was rarely or never understood and had severely impaired decision-making skills, and his care plan documented total dependence on staff for dressing tasks. The ADON stated she did not know why the resident was not wearing clothing, later reporting that staff said the family had not provided clothing, and the Administrator confirmed the resident had not worn a gown since admission with no documentation explaining why, despite a resident rights policy requiring care to be provided in a manner that promotes dignity.
Failure to Assess and Observe Resident Medication Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to complete a Self-Administration of Medication assessment and to observe medication administration for a resident who was effectively allowed to self-administer a drug. During observation, an LPN placed a cup containing one 500 mg acetaminophen tablet and a cup of water in front of Resident 5 and then left the room without maintaining visual observation of the resident consuming the medication. Resident 5 had diagnoses including gout, bilateral leg pain, depression, post-traumatic stress disorder, and dysphagia, and their most recent quarterly MDS showed a BIMS score of 15, indicating they were cognitively intact. Physician orders directed that one 500 mg acetaminophen tablet be administered three times daily for pain, but there was no order authorizing the resident to self-administer this medication. Review of clinical assessments over the period from 1/1/25 to 4/24/26 showed that no Resident Medication Self-Administration Assessment had been completed for this resident. The DON stated that staff were required to watch the administration of medication for each resident, and that residents could only self-administer medications when a Self-Administration Assessment had been completed and determined appropriate or when there was a specific order for self-administration. The facility’s current policy, dated 12/1/07, required staff administering medication to observe the resident’s consumption of the medication. Despite these requirements and the resident’s documented dysphagia, the LPN did not remain to observe the resident taking the acetaminophen, and no self-administration assessment or order was in place, resulting in noncompliance with facility policy and 410 IAC 3.1-11(a).
Failure to Notify Emergency Contacts of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure required bed-hold policy notification was provided to residents’ emergency contacts during hospital transfers. For one resident with chronic kidney disease, diabetes, and a seizure disorder, the record showed a BIMS score of 15, indicating no cognitive deficit. A progress note documented that the physician ordered a hospital transfer when the resident was not responding, and an Indiana Bed Hold Notification was signed by the resident declining to have the bed held. The Administrator stated that the resident was their own responsible party, but also indicated that the resident’s sister was both the durable power of attorney and emergency contact, and that she should have been contacted when the resident was not responding. There was no documentation that the emergency contact was notified of the bed-hold policy. For a second resident with atrial fibrillation, lumbar fracture, lumbar wound dehiscence, and malnutrition, the discharge MDS and care plan documented severe cognitive impairment. A progress note indicated the resident was transferred to the hospital and that the bed-hold policy was sent with the EMT, and that the emergency contact was made aware of the transfer. However, neither the progress note nor the transfer form documented that the emergency contact was informed of the facility’s bed-hold policy. An Indiana Bed Hold Notification was signed by the resident declining to have the bed held, despite the documented severe cognitive impairment. The Administrator confirmed that this resident was cognitively impaired and that the emergency contact should have been notified of the bed-hold policy. No facility policy on bed-hold notification was available for review at the time of exit.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure proper oral hygiene for a resident who was entirely dependent on staff for all aspects of care. The resident, diagnosed with cerebral palsy, curvature of the spine, and curvature of the neck, was observed multiple times with their mouth open, tongue protruding, and lips dry with white caking. The resident's tongue was also covered with a dry, white coating. The resident's care plan indicated they were totally dependent on staff for oral care, and the facility's policy required oral care every 2 to 4 hours for dependent residents. However, observations and interviews revealed that the resident did not receive the necessary oral care, as confirmed by a registered nurse who noted the resident's extremely dry lips and tongue and acknowledged the need for oral care every 2 hours.
Failure to Maintain Tube Feeding Supplies
Penalty
Summary
The facility failed to ensure proper maintenance of a tube feeding for a resident diagnosed with cerebral palsy, curvature of the spine, and curvature of the neck. The resident, who was severely impaired and entirely dependent on staff for care, was observed with a tube feeding pump in their room. The resident's care plan indicated a requirement for tube feeding with nothing by mouth. However, the tube feeding formula and water containers were dated two days prior, indicating they had not been changed as required. A registered nurse confirmed that the tube feeding supplies were supposed to be changed daily and labeled with the date and time, in accordance with the facility's policy on enteral nutrition therapy, which mandates replacement every 24 hours.
Failure to Ensure Freedom from Unnecessary Medications
Penalty
Summary
The facility failed to ensure freedom from unnecessary medications for a resident, identified as Resident 17. The resident's medical record was reviewed, revealing diagnoses of diabetes, chronic kidney disease, Parkinson's, and coronary artery disease. The resident's Quarterly Minimum Data Set indicated no cognitive loss and the requirement of an indwelling urinary drainage catheter. A physician order dated June 12, 2024, prescribed an antibiotic injection for three days for a urinary tract infection (UTI). However, a progress note dated June 20, 2024, indicated that the antibiotics were completed for an unknown infection, and a medication error was made by the prescriber, as there was no urinalysis to support the UTI diagnosis. The Medication Administration Record confirmed the administration of the antibiotic injections on June 11, 12, and 13, 2024. During an interview, the Administrator was unaware of the resident receiving antibiotics without an infection. The facility's policy on medication-related errors required staff to follow incident policy and performance improvement processes in such cases.
Recurrent Environmental Concerns Not Addressed
Penalty
Summary
The facility failed to ensure quality improvement plans were developed for identified recurrent environmental concerns. During the annual survey completed on 6/7/23, issues regarding the repair and maintenance of facility floors, walls, and handrails were identified. The facility committed to correcting these issues by 6/30/23. However, the same concerns were found again during the annual survey completed on 3/28/24, indicating that the issues had not been adequately addressed or resolved. The QAPI committee, which includes various department heads such as the Executive Director, Director of Nursing Services, and Maintenance Director, reviewed segments of care including maintenance in their monthly meetings. Despite the ongoing discussion of environmental issues in these meetings, there was no current performance improvement plan in place to address the environmental deficiencies. This lack of a formalized plan contributed to the recurrence of the same issues in subsequent surveys.
Facility Failed to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to ensure a sanitary environment free of hazards on four halls where residents resided or received services. Observations revealed that handrails on the 200, 300, 400, and 500 halls had bare portions missing finish, and baseboards were missing throughout the 100, 200, 300, 400, and 500 halls. Additionally, drywall on portions of the walls below the handrails had grey linear marks scattered throughout, and the bottom of the drywall had chipped, jagged edges observed on all halls. A raised buckle in the vinyl plank flooring was observed on the 100 hall near the door to the maintenance office, and similar buckled areas were identified outside multiple rooms across different halls. The Maintenance Director indicated that repairs had been delayed due to problems with the company contracted to install flooring throughout the building and that he was not aware of any current plans for contractors to fix the flooring problems. The Executive Director, who began work in December 2023, was also not aware of any plans for repairs of the floor and had not been aware of handrail concerns. The facility's current policy titled Plant Operations, last reviewed on 7/12/23, indicated that the facility should maintain a safe, clean, and structurally sound environment. However, the observations and interviews conducted during the survey revealed that the facility had not adhered to this policy, resulting in an environment that was not safe, clean, or structurally sound. The Maintenance Director and Executive Director both acknowledged the issues but indicated that there were no current plans to address the flooring and handrail concerns. The findings highlight a significant deficiency in maintaining the facility's physical environment, which could potentially impact the safety and well-being of the residents, staff, and the public.
Failure to Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure nurse staffing hours were posted daily for 3 of 4 days reviewed. On multiple observations on 3/24/24, the nurse staffing hours posted near the facility entrance were dated 3/21/24. Interviews with the Director of Nursing (DON) and the Administrator revealed that both were unaware that the nurse staffing hours had not been updated for three days. The facility's current policy, dated 4/24/19, mandates that nurse staffing data must be posted every day at the beginning of each shift.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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