Legacy Park Health: Medical Record Failures - TN

The medication mistake at Legacy Park Health and Rehabilitation left the resident's daughter finding her mother "out of it and couldn't speak" when she returned from a trip in August 2024. Federal inspectors found the facility's quality assurance program failed to prevent the error or implement effective corrections afterward.

Resident #7 had been admitted for five days of respite care with orders for morphine concentrate to be given every two hours as needed for shortness of breath. Licensed Practical Nurse A transcribed the order as a scheduled medication instead of as-needed. The facility administered morphine every two hours around the clock — 12 doses on August 9, eight doses on August 10, 12 doses on August 11, and 11 doses on August 12.

The error was discovered only when the resident's daughter complained to nursing staff. Even then, administrators corrected the scheduling mistake but failed to notice they had documented the wrong concentration of morphine on the medication record. Inspectors found this second error during their February visit.

The facility's performance improvement plan addressed only the scheduling mistake. Director of Nursing staff educated one nurse who had missed the transcription error but never trained the agency nurse who made the original mistake. No facility-wide education occurred. No communication with the hospice agency addressed unclear orders.

"The DON stated she did not educate the agency nurse who transcribed the morphine incorrectly because she was not her (facility) employee," inspectors wrote.

The quality assurance failures extended beyond medication errors. Inspectors found systematic documentation problems affecting five residents with urinary catheters. Despite facility policies requiring staff to record urine output amounts, no documentation existed for any of these residents over periods spanning weeks or months.

Resident #2, who had moderate cognitive impairment and an indwelling catheter, had no urine output documented from November 21 through December 5, 2024. The medical record also lacked documentation that the catheter had been replaced on December 4, despite shift reports and nurse notes referencing the change.

Three other residents with catheters had comprehensive care plans specifically requiring staff to "monitor intake and output as per facility policy." Resident #17's plan noted the catheter put him "at risk for complications and UTI." Resident #18's catheter was related to pressure ulcers. Resident #19's plan instructed staff to "monitor/record/report to MD for no output."

None had any urine output documented for January and February 2025.

The documentation failures carried clinical significance for Resident #10, who had a history of catheter-associated urinary tract infections with sepsis. His care plan required staff to observe for signs of infection including "decreased output" and report abnormalities to physicians. On July 12, 2024, he reported extreme genital pain rated 10 out of 10 and requested emergency room transport.

Inspectors found no SBAR communication form in his medical record, despite facility policy requiring detailed documentation when residents are transferred to hospitals.

During interviews, the Director of Nursing confirmed staff expectations to document urine output and catheter changes. The Assistant Director of Nursing acknowledged the documentation failures for residents with catheters.

The quality assurance committee's response to the morphine overdose revealed broader systemic problems. The Director of Nursing said the committee included herself, the assistant director, unit manager, MDS nurse, and wound care nurse. She claimed they performed "routine random audits" but had no documentation of any audits and no records they were ever completed.

The performance improvement plan for the medication error listed four corrective actions: identifying affected residents, educating one nurse, discussing hospice order formats in team meetings, and having administrators check admission orders. The plan did not include root cause analysis, facility-wide training, or communication with outside agencies involved in the error.

"The QAPI Committee failed to ensure an effective Quality Assurance Program was in place to monitor and evaluate concerns related to significant medication errors," inspectors concluded.

The facility operates as Shannondale Health Care Center at 7424 Middlebrook Pike. The inspection occurred following complaints and resulted in citations for failing to maintain complete medical records and inadequate quality assurance programs.

Federal inspectors found the documentation failures and quality assurance problems affected resident safety and care coordination. The morphine overdose patient's daughter discovered the medication error, not facility monitoring systems designed to prevent such incidents.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Legacy Park Health and Rehabilitation from 2025-02-27 including all violations, facility responses, and corrective action plans.

Additional Resources

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