Failure to Implement Psychiatric Care Policies Leads to Resident's Death
Summary
The deficiency in the facility's care was primarily due to the failure of the Medical Director to implement resident care policies and coordinate medical care for a resident, identified as R84. R84 was admitted with a Level 2 PASRR indicating a need for monthly psychiatric services, which the Medical Director was unaware of. Consequently, the facility did not provide the necessary psychiatric services. This oversight was a significant factor leading to the resident's tragic death by suicide, as the resident was found deceased with oxygen tubing wrapped around her neck. R84 had a history of major depressive disorder, schizoaffective disorder, and generalized anxiety disorder. Despite having a care plan that included interventions for these conditions, there was no documented evidence that the Medical Director or other staff followed up on missed psychiatric appointments or the resident's refusal of facility-provided psychiatric services. The Medical Director, who was also the resident's primary care physician, noted the resident's conditions as stable in several progress notes but did not address the lack of psychiatric care or the resident's refusal to engage with the facility's psychiatric services. Interviews with staff revealed that there were signs of mood changes in R84, particularly after interactions with her spouse, but these were not adequately addressed. The former Social Services Director noted a high score on the PHQ-9 depression scale for R84 but did not pursue alternative psychiatric services after the resident refused the facility's provider. The lack of communication and coordination among the facility's staff, the Medical Director, and external psychiatric providers contributed to the failure to provide necessary psychiatric care, ultimately leading to the resident's death.
Penalty
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Physician orders were not carried out for two residents. One resident with anemia and other chronic conditions had handwritten orders for iron, Vitamin C, and Vitamin B-12 after abnormal CBC results, but staff could not find the orders entered in the EHR. Another resident with a history of blood clots, morbid obesity, and arthritis had a handwritten order to start Zepbound weekly, but there was no documentation that the order was addressed or entered. The PA, MD, DON, and RNS described gaps in how orders were communicated and entered into the medical record.
The facility did not ensure the Medical Director coordinated medical care for the Westminster unit. Surveyors found no documented evidence that the Medical Director reviewed the Facility Assessment, helped develop abuse prevention policies, or attended the most recent QA meeting. The Medical Director said they reviewed incident investigations and had assessed a resident after an abuse incident, but could not provide documentation, and were unaware the resident had not been seen by a psychiatrist as required.
Medical director oversight failed when an antipsychotic was continued for a resident with severe vascular dementia and psychotropic disturbances without clear documentation supporting schizophrenia. The chart showed Invega Sustenna was ordered for dementia-related psychotic disturbance, while a psych note listed schizophrenia and the PMHNP said they did not diagnose schizophrenia and had followed prior orders. The medical director stated they signed off on meds but did not know why the EHR listed dementia, did not know the psych note showed schizophrenia, and did not know whether a GDR or diagnostic assessment had been done.
A resident with mild cognitive impairment and poor decision-making ability was documented as lacking capacity, yet the MD was listed as the surrogate decision-maker. Facility policy required help obtaining an unaffiliated RP when a resident could not make decisions, but the resident’s sister was not used and no documentation showed that the Department of Aging obtained a patient representative. The MD stated she knew the resident for years, did not know the RP policy, and agreed to act as the resident’s decision maker.
The facility failed to ensure the MD carried out MRR responsibilities for 3 residents reviewed for medications. The Interim CEO confirmed there was no documentation showing the MD completed monthly pharmacy recommendation reviews or signed the pharmacy reports, and the MD did not return the surveyor’s call before exit. The facility’s MRR policy requires monthly pharmacist review of each resident’s drug regimen and chart, with staff acting on recommendations.
Medical Director Oversight of Resident Tube Feeding and Medication Care: The facility failed to ensure the MD provided appropriate oversight of care for a resident with a g-tube, moderate cognitive impairment, hyperparathyroidism with hypercalcemia, and multiple medications given via the tube. The resident’s care plan lacked key details for skin breakdown, refusal of care, fluid balance, HOB elevation timing, and monitoring for endocrine-related symptoms, while the physician orders lacked electrolyte monitoring, I&O tracking, medication interaction management, and guidance for symptoms or refusals. Interviews showed the PA was unsure about electrolyte monitoring and relied on consulting services and the pharmacist, while the DON stated the MD was new to the role and seeing outpatients.
Physician Orders Not Carried Out for Two Residents
Penalty
Summary
The facility failed to carry out physician orders for two residents reviewed for unnecessary drugs. One resident had diagnoses including anemia, low thyroid level, depression, high blood pressure, and a fracture of the thighbone. A review of the resident’s CBC dated 3/10/26 showed low hemoglobin and other abnormal anemia-related markers, and the paper record contained handwritten orders for an iron pill, Vitamin C, and Vitamin B-12 signed by a PA. During interview and record review, the RNS stated she could not find any corresponding orders entered into the electronic health record and was unsure why the orders were not communicated to nursing staff for entry. The PA stated he signed the paper sheet and wrote the orders on the lab sheet, did not enter orders into the computer, and was not sure why the orders were not carried out. The MD stated providers had access to the facility computer system and that it was a shared responsibility to ensure orders were entered timely. A second resident had a history of blood clots, morbid obesity, and arthritis. In the resident’s H&P dated 4/29/26, MD 2 wrote a handwritten order to start Zepbound 2.5 mg weekly. Review of the electronic record, including nursing notes and provider follow-up notes, did not show that the order was addressed or carried out. The DON and RNS stated they could not find documentation that the Zepbound order was entered, and the RNS said nursing staff did not see the new order listed at the bottom of the H&P sheet to address and input into the computer. The MD again stated providers had access to the computer system and could enter orders, and that it was a shared responsibility to ensure orders were entered in the medical record in a timely manner. The facility did not provide a policy on medical provider and director roles and responsibilities.
Medical Director Not Fully Involved in Facility Oversight
Penalty
Summary
The facility did not ensure the Medical Director was responsible for coordinating the medical care of the Westminster Unit. Survey findings showed there was no documented evidence that the Medical Director reviewed the Facility Assessment dated [DATE], participated in the development of facility policies and procedures to prevent abuse, or attended the most recent quality assurance committee meeting held on 04/23/2026. The Medical Director stated they had been involved in prior quality assurance meetings and had reviewed resident care policies when they took the role, but they did not know what topics were discussed at the most recent meeting and provided no evidence of involvement in the Facility Assessment. Interviews also showed the Medical Director had been the attending physician for the Westminster Unit until about one month before the interview, while Nurse Practitioner #1, employed through the Medical Director’s third-party staffing agency, had been assigned full-time to cover three units including Westminster and answered directly to the Medical Director. The Medical Director stated they were responsible for reviewing incident investigations and had assessed Resident #1 after an abuse incident, but they could not provide documented evidence of that assessment and were unaware that Resident #1 was not assessed by a psychiatrist as required by the facility’s incident investigation. The Administrator stated the facility would be using an outside consulting agency to help address resident care and abuse prevention and reporting policies.
Medical Director Did Not Verify Appropriateness of Antipsychotic Use
Penalty
Summary
The facility failed to ensure the medical director verified the appropriateness of an antipsychotic medication for one resident. Resident #4 had diagnoses including severe vascular dementia with psychotropic disturbances, depression, and an anxiety disorder due to a known physiological condition. The resident had an active order for Invega Sustenna 156 mg/mL once a day on the 10th of the month, and the record showed it was prescribed for vascular dementia with psychotic disturbances. A quarterly assessment showed the resident did not have indicators of psychosis such as hallucinations or delusions and did not have a diagnosis of schizophrenia. A psychiatry services note later documented schizophrenia and included Invega Sustenna 156 mg/mL in the treatment plan, but there was no documentation that the resident had been assessed for schizophrenia before that diagnosis and treatment. The PMHNP stated they did not diagnose the resident with schizophrenia and had followed the previous provider's orders, and they did not know who diagnosed the resident with schizophrenia. The medical director stated they oversaw medications prescribed by psych services and signed off on all medications, but they did not know why the EHR showed Invega Sustenna was prescribed for dementia, did not know the psych notes showed schizophrenia, did not know where to find the psych notes, and did not know whether a GDR had been attempted or whether any assessments had been done to diagnose schizophrenia.
Medical Director Served as Resident’s Decision Maker Without Unaffiliated RP
Penalty
Summary
The facility did not ensure that the Medical Director effectively implemented resident care policies for one sampled resident when it failed to obtain a resident representative who was unaffiliated with the facility. Facility policy stated that the facility was responsible for assisting residents in obtaining a representative if they could no longer make their own decisions or had no family to fill that role, and the compliance manual stated employees should not place themselves in positions involving conflicts of interest. Resident 8 was admitted with mild cognitive impairment, and later assessment showed poor decision-making ability. The resident’s record also stated that he did not have capacity to make decisions and that the surrogate decision-maker was the MD. The MD documented that the social services director informed her that the resident refused to have his sister as decision maker, and the MD then asked the resident if she could be his decision maker if he was not able to decide for himself; he agreed. The DON stated the resident did not currently have an RP and that the MD was acting as an intermediary between the resident and his sister. The MD stated she knew the resident for 15 years, did not know the facility policy on responsible parties, and did not contact the Department of Aging for a patient representative because the resident would not be able to express what he wanted to someone he did not know. The SSD believed the DON had contacted the Department of Aging, but no documentation was produced showing that a patient representative had been obtained.
Medical Director Did Not Complete Monthly Pharmacy Review Documentation
Penalty
Summary
The facility failed to ensure the Medical Director fulfilled responsibility for implementing Medication Regimen Review (MRR) policies and coordinating medical care between the facility and the consulting pharmacist/pharmacy for 3 residents reviewed for medications. During interview, the Interim CEO confirmed that the facility did not have documentation showing that the Medical Director had completed monthly pharmacy recommendation reviews for the three residents, and confirmed that the Medical Director was responsible for ensuring all resident pharmacy reports were reviewed and signed. The report also states that the Medical Director did not return the surveyor’s telephone call before survey exit. Review of the facility’s MRR policy dated 4/24/24 showed that each resident’s drug regimen is to be reviewed at least monthly by a licensed pharmacist and that the review includes the resident’s medical chart, with staff acting on recommendations according to facility procedures.
Medical Director Oversight of Resident Tube Feeding and Medication Care
Penalty
Summary
The facility failed to ensure the medical director provided appropriate oversight of resident care policies and coordination of medical care for a resident who had a gastrostomy tube and multiple ongoing medical issues. The resident had moderate cognitive impairment, used a walker, and required hydration and nutrition through a g-tube. Her care plan addressed urinary incontinence and potential pressure ulcer development, but it did not identify actual skin breakdown on the coccyx, did not include goals or interventions for the resident’s refusal of cares and treatments, did not address her risk for fluid-volume imbalance, and did not include specific time requirements for elevating the head of the bed during and after tube feedings. The care plan also lacked specific symptoms, side effects, and monitoring related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The resident’s physician orders included tube feedings, water flushes, and multiple medications administered through the g-tube, including levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol, senna, cinacalcet, omeprazole suspension, and ascorbic acid. The orders lacked monitoring of electrolytes, accurate intake and output, fluid balance management related to tube feedings and free water, medication interaction monitoring and interventions to prevent adverse effects, a process for monitoring ongoing symptoms such as nausea, vomiting, and abdominal pain, and guidance for when staff should alert the provider if the resident refused medications or treatments. During interviews, the PA stated the resident had a complicated GI tract and hyperparathyroidism causing hypercalcemia, and that electrolyte imbalances would remain an ongoing concern. The PA stated she did not have plans to order follow-up bloodwork because she thought consulting services would monitor electrolytes, and she was unsure of the electrolyte monitoring schedule and the nutrition team’s involvement. The DON stated the medical director was seeing patients at his outpatient clinic, had been in the role only a short time, and this was his first medical director position in LTC. Additional interviews showed the PA relied on the pharmacist for timing medications in relation to tube feedings and had not directly communicated the resident’s medication needs to the consultant pharmacist. The facility Medical Director Responsibilities policy stated the medical director was responsible for coordination of medical care, implementation of resident care policies, and ensuring the appropriateness and quality of medical care.
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