Citations in Indiana
Statistics, citations and compliance trends for long-term care facilities in Indiana.
Statistics for Indiana (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Indiana
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Indiana
- Developed a sling replacement schedule per manufacturer instructions to help ensure slings were replaced before becoming unsafe (J - F0689 - IN)
- Added sling sizing guidance to resident care plans and CNA care guidance to support correct sling selection during mechanical lift transfers (J - F0689 - IN)
- Reeducated staff on identifying sling pad deterioration before use to prevent use of compromised slings (J - F0689 - IN)
Failure to Transcribe Hospital Diabetes Orders Resulting in Missed Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and enter a hospital’s discharge orders for a newly admitted resident with type 2 diabetes into the facility’s electronic health record. The resident was admitted for a short-term rehab stay with diagnoses including type 2 diabetes, acute upper respiratory infection, unspecified dementia, weakness, dehydration, and hydrocephalus. The hospital discharge orders dated 2-6-26 specified that the resident had type 2 diabetes and was to receive glargine (Lantus) 16 units subcutaneously twice daily, with blood glucose (BG) monitoring before meals or three times daily. These diabetes-related orders, including the diagnosis and insulin regimen, were not transcribed into the facility’s electronic health record at admission and were not entered until 2-12-26. Multiple facility staff, including the Director of Health Services (DHS), MDS staff, a Nurse Practitioner, and two nurses, reviewed the hospital discharge paperwork and entered orders into the electronic health record but failed to identify and transcribe the diabetes diagnosis and associated insulin and BG monitoring orders. The DHS later explained that the initial page of the hospital discharge summary did not specifically mention the diabetes diagnosis, which was located further into the document, and that staff did not locate this information during the initial review. The omission was discovered on 2-11-26 during an initial care planning meeting when a family member inquired about the resident’s BG levels, prompting a more thorough review of the hospital discharge documents. During the period when the diabetes diagnosis and insulin orders were not in place, the resident did not receive the ordered long-acting insulin for five days and had only one insulin injection documented since admission. The resident’s BG levels during this time were significantly elevated, with readings including 399, 451, 496, 316, 360, 356, 422, and 354. The resident, who was already severely cognitively impaired per the 5-day MDS assessment, experienced diminished cognitive levels and lethargy and was ultimately sent to the local hospital at the family’s request. Hospital records from that subsequent admission documented altered mental status possibly related to dehydration, infection, or diabetic ketoacidosis, and identified the resident’s diabetes as uncontrolled at that time.
Removal Plan
- notification of the physician and the responsible party of the identified issues
- obtaining updated physician orders
- implementing the orders
- educating the licensed nursing staff on the facility's policies related to transcribing physician orders and diagnoses from the discharging entity into the facility's electronic health record
- initiated an audit system to ensure residents had accurately transcribed admission orders and diagnoses correctly documented into the facility's electronic health record system
Failure to Prevent and Manage Progressive Sacral and Buttock Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and deterioration of a severe pressure ulcer in a resident who was admitted without documented pressure injuries to the buttocks or sacrum, despite being identified as at increased risk for skin breakdown. On admission, the resident had diagnoses including a displaced intertrochanteric fracture of the left femur, difficulty walking, morbid obesity, and bilateral hip osteoarthritis. The admission nursing evaluation documented normal skin color and temperature, with excoriations noted on the chest and bilateral iliac crest/groin areas, and a surgical dressing on the left thigh, but no pressure injuries were documented. A Braden Scale completed at admission identified the resident as at increased risk for pressure sores, with limited cognition, chairfast status, limited mobility, and friction and shear as potential problems. The care plan initiated the day after admission identified potential for skin impairment related to decreased mobility and included general interventions such as incontinence care, treatments as ordered, observation of skin during care, turning and repositioning, use of a pressure-reducing mattress and wheelchair cushion, weekly skin checks, and a wheelchair cushion, but no new or revised interventions were added when the care plan was revised several days later. Subsequent skin checks documented a stage 1 pressure injury to the medial buttocks that was considered present on admission, although the admission assessment had only described excoriation and did not stage a pressure injury. A skin check dated approximately nine days after admission described the buttocks as having a generalized stage 1 pressure ulcer/injury to the medial buttocks without undermining or tunneling, and a later skin check again documented a stage 1 pressure injury to the medial buttocks, still described as present on admission. The resident’s MDS indicated she was cognitively intact but totally dependent on staff for toileting, hygiene, showering, and transfers using a sit-to-stand device, and required substantial assistance for bed mobility and position changes. The DON later reported that the resident slipped from the bed on an early March date and that shearing was subsequently noticed, which was described as the resident’s skin tears. Despite the resident’s high risk status, dependence on staff for repositioning, and documented redness on the coccyx and buttocks, there is no indication in the record that the facility implemented additional or modified interventions beyond the original care plan to address the evolving skin issues. A wound note dated in early March documented that the resident, in addition to her post-surgical left proximal and distal wounds, had full-thickness skin tears to the right and left buttocks and sacrum. A physician’s order for non-pressure wounds of the coccyx and bilateral buttocks directed cleansing with normal saline, application of calcium alginate, and dressing as needed. A nurse’s note the same day indicated the resident was seen via telehealth by the wound nurse with the assistant DON, and the plan was for twice-daily dressing changes using Dakin’s solution, calcium alginate, and abdominal gauze. The following day, a wound note documented selective debridement of the right buttock and surgical excisional debridement of the sacrum. A subsequent alert note described the buttock/sacrum wound as tunneling with foul odor, requiring flushing with Dakin’s and normal saline, and application of Santyl, calcium alginate, and border gauze. Shortly thereafter, the resident was sent to the hospital for lethargy, altered mental status, and elevated temperature, and the hospital documented a diagnosis of sepsis likely due to an infected sacral wound. The surveyors determined that the facility failed to prevent the development and progression of a stage 4 pressure ulcer on the sacrum and full-thickness skin tears on the bilateral buttocks, and failed to ensure appropriate services were provided to these wounds, resulting in deterioration to a stage 4 pressure injury requiring surgical debridement and hospitalization for sepsis within three weeks of admission.
Removal Plan
- staff education/in-services on daily wound monitoring
- assess all residents for identifying skin impairments
- review all resident care plans regarding skin issues
- ensure pressure injury prevention interventions are in place for at-risk residents
- wound team to complete a risk management assessment of physician notification, obtaining new orders, transcribing new orders, contacting families regarding new orders, updating care plans with new interventions, and providing therapy referrals as needed
Improper Sling Selection and Use Leads to Fatal Mechanical Lift Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff used a correctly sized, properly labeled, and intact mechanical lift sling when transferring a resident, and to have an effective process for sling sizing and condition assessment. A resident with hemiplegia affecting the left side and a left above-knee amputation required transfers with a Hoyer (mechanical) lift and assistance of two staff. The resident’s MDS documented a height of 78 inches (6 feet 6 inches) and weight of 252 pounds. The resident’s care plan and physician orders specified use of a Hoyer lift with two staff for transfers but did not identify the size of sling to be used. There was no documentation of an interdisciplinary assessment to determine appropriate sling size prior to using the lift, and no physician orders specifying sling size. During a transfer from bed to chair, an LPN and a CNA used a blue sling with four straps and color‑coded rings. The CNA reported that the sling straps were inspected before use and did not appear worn, though she described the sling as old. The straps were attached to the lift bar using the last black ring on each strap to accommodate the resident’s size. While the resident was suspended in the lift and being moved backward, the black ring on the left bottom (leg) strap broke in the middle, causing the resident to fall from the sling, strike his head on a bed frame, and land on the floor. The resident briefly lost consciousness, then became lethargic and complained of pain in the head, back, and hips. Vital signs were obtained and the NP was notified, who ordered transfer to the hospital. Hospital CT scans later showed multiple fractures of the lower back, pelvis, and neck, and the resident died at the hospital. Subsequent observation of the sling in the Administrator’s office showed a blue sling with pilling along the edges, a torn black ring on the left bottom strap, and a worn, torn label with no legible writing. There were no visible tags identifying sling size or directions for use. Facility documentation for the sling model indicated that a large universal sling was generally intended for patients 225–325 pounds and 5 feet 5 inches to 6 feet 1 inch tall, and that sling size and fit could vary based on weight and girth, with physician consultation recommended for sling selection. Staff interviews revealed that, prior to the incident, all slings in use were the same size, residents did not have specific sling sizes assigned, and staff did not know who was responsible for monitoring slings for age or defects. The Rehabilitation Director stated that rehab evaluated residents for need of mechanical lifts but did not determine sling size, and that staff were expected to follow sling label directions, even though the sling involved had an illegible tag. External guidance from the FDA and a sling manufacturer emphasized the need to select sling size based on patient measurements and manufacturer recommendations, and to remove slings from service if tags were missing, faded, or illegible, or if deterioration was present. The facility’s own policy required availability of varying sling sizes, correct resident measurement per manufacturer instructions, and removal of damaged or unsafe slings from service, which was not carried out in this case.
Removal Plan
- Removed all lift pads from service
- Assessed residents utilizing lifts for proper fit according to manufacturer's guidelines
- Replaced all slings with properly sized slings
- Added sling sizing to care plans and care guidance for CNAs
- Developed a replacement schedule for slings according to manufacturer's instructions
- Reeducated staff on how to identify deterioration of sling pads before use
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