Deficient Ventilator Care and Physician Oversight
Summary
The facility failed to ensure that residents requiring ventilator care received ongoing medical supervision and oversight by a physician. This deficiency was identified for nine out of fifteen residents reviewed for ventilator care, indicating a systemic failure in the interdisciplinary approach and physician oversight. The lack of adequate implementation of policies and procedures to monitor and supervise the weaning process for mechanical ventilation, as well as responding to mechanical ventilation alarms and respiratory needs, increased the likelihood of serious harm, injury, or death. One resident, who was admitted with multiple serious health conditions including acute and chronic respiratory failure and was ventilator-dependent, experienced a significant change in condition during an attempted weaning process. The resident was not tolerating the weaning, as indicated by persistent low minute volume alarms, low respiratory rate, and grayish skin. Despite these signs, there was no documented physician assessment or evaluation to determine the resident's eligibility for weaning, no weaning parameter orders, and no notification to the physician about the change in condition. The resident was later found unresponsive and pronounced dead. Interviews with facility staff revealed a lack of clear protocols and communication regarding the weaning process and physician involvement. The respiratory therapist and nurse involved in the resident's care were unsure of who decided the resident was eligible for weaning and did not notify the physician of the resident's deteriorating condition. The facility's pulmonologist was not frequently present, and there was no documentation of their assessments or evaluations in the residents' medical records. This lack of oversight and documentation contributed to the deficient practice in the facility's ventilator care management.
Removal Plan
- The NHA notified the Medical Director of the incident.
- The Pulmonologist will complete physical assessments on all like residents to identify any changes in condition and confirm current ventilator settings.
- The Pulmonologist has received education outlining responsibility for oversight for respiratory care for all Ventilator residents including but not limited to completing physical assessments, monitoring ongoing care, documenting consultations/evaluations, providing orders for weaning for ventilator residents.
- The pulmonologist has agreed to round for the residents on the ventilator unit at least 2 times per week. She is available to take call 24 hours in coordination with Primary Care Provider.
- Ventilator orders sets are entered on admission.
- Oxygen: RUN @ L/MIN VIA N/C MASK TRACH HOURS PER DAY PRN CONTINUOUS.
- Assess stoma site and under trach collar.
- Trach Change. Trach brand: Trach size:
- Change trach collar/strap every 3 days and prn.
- Visual check of ventilator dependent residents per care plan and prn.
- Weaning prn, per physician order, or respiratory protocol.
- Enter time in minutes to complete airway equipment management task.
- Evaluation/Assessment of resident on (Vent/Tracheostomy).
- Oxygen saturation q shift and prn.
- Oxygen tubing/filter change every week. Enter time in minutes to complete task.
- Suction tracheostomy as needed.
- Resident/Resident Representative Education.
- Trach Care PRN (as needed).
- Trach tie change with baths and as needed.
- Settings: Mode: RR: PEEP: PS:
- Change circuits monthly and PRN. Enter time in minutes to complete circuit change task.
- Trach care every shift and as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide physician reassessment after a significant change in condition: a resident with a large, foul-smelling scalp lesion was found to have maggots in the wound. Staff notified the MD, who gave wound care instructions by phone, but did not come to assess the resident or document a reassessment before the resident’s outpatient surgery visit.
A resident with sleep apnea, chest pain, and abnormal EKG had cardiology-ordered diagnostic tests entered into the chart, including a nocturnal desaturation study, Lexiscan MIBI stress test, and echocardiogram. Staff stated the attending physician had to sign off on the cardiologist’s recommendations before the appointments could be scheduled, but the orders were not signed in a timely manner and the signed fax was sent to the wrong number, leaving no record of scheduled appointments or results.
Delayed Physician Response for Resident With UTI Symptoms: A resident with a UTI diagnosis and severe cognitive impairment reported burning and pain with urination, but the physician did not respond promptly to repeated nursing calls. Staff waited for orders, urine testing was delayed and required recollection, and an initial antibiotic order was later stopped when the resident’s PCN allergy was identified. The first dose of the alternate antibiotic was given nearly three days after symptoms were first reported, and the DON stated the Medical Director should have been contacted after unanswered attempts.
A facility failed to ensure physician orders were in place for residents admitted to the Alzheimer's secure care unit, and one resident also lacked a qualifying dementia diagnosis for that placement. Records showed several residents in the secure unit without the required order, while staff interviews confirmed the admission nurses, nurse managers, ADON, and DON were responsible for obtaining and monitoring those orders. The DON stated the orders had not been properly entered into the system, and the MD said residents admitted to secure units should have physician orders and a medical diagnosis of dementia before placement.
Failure to Obtain Physician Orders for Weight Monitoring: A resident with chronic respiratory failure, ventilator dependence, heart failure, and obesity had a major unplanned weight gain over several months, but the chart showed no physician notification, no orders for daily/weekly/monthly weights, and no documented follow-through on weight monitoring. CNA, LPN, and RD interviews confirmed the resident was not on a weight-monitoring list and no physician orders were present in the record.
A resident developed a Stage 3 sacral pressure ulcer that was documented by nursing and the wound NP, but the resident’s primary MD and facility NP repeatedly failed to identify or assess the wound during multiple visits. The facility policy required the attending physician to evaluate and document wound healing, and the DON confirmed the concern. The NP stated she did not include the wound in her notes because the wound team was following it.
Failure to Provide Physician Reassessment After Maggot-Infested Scalp Wound
Penalty
Summary
The facility failed to ensure physician supervision and ongoing clinical oversight after being notified of a significant change in condition for one resident with a large scalp lesion. During observation, the resident had multiple black-colored lesions on the scalp, including a large central lesion about the size of a tennis ball that was partially covered with brown material and had yellowish, foul-smelling drainage. Staff reported that the resident was admitted with the lesion, that it intermittently drained, and that on 6/12/26 a staff member found maggots in the wound. After the maggot infestation was reported, a staff member assessed the resident and called the physician, who instructed staff to clean the area with soap and water, apply petroleum jelly, and cover the wound. The resident received a shower and the lesion was dressed per orders, but the physician did not come to the facility to assess the resident after notification. The physician later stated he did not evaluate or reassess the resident because an outpatient general surgery appointment was already scheduled. Record review showed no physician progress note documenting reassessment of the resident’s condition between the report of maggots and the outpatient surgical evaluation.
Physician Orders for Diagnostic Tests Were Not Timely Signed
Penalty
Summary
The facility failed to ensure necessary physician services were provided for one resident when cardiology-ordered diagnostic tests were not promptly signed by the attending physician for scheduling. The resident was admitted and readmitted to the facility, had capacity to understand and make decisions, and had a cardiology appointment that resulted in new orders for a nocturnal desaturation study, a Lexiscan MIBI stress test, and an echocardiogram for sleep apnea, chest pain, abnormal EKG, and chest pain. The resident’s nursing progress note stated the orders were noted and carried out, and the order summary showed the three diagnostic tests were entered. However, the medical record did not show scheduled appointments or results for the tests. During interview and record review, RN staff stated the facility needed the attending physician to sign off on the cardiologist’s recommendations before appointments could be scheduled, and that multiple attempts were made to contact the physician. The resident’s orders were not signed until later by another attending physician, and the physician office staff stated the signed orders had been faxed to the wrong fax number and were not accurately received by the facility.
Delayed Physician Response for Resident With UTI Symptoms
Penalty
Summary
The facility failed to ensure a physician responded to staff phone calls or that the Medical Director was contacted when a resident reported pain and burning with urination. The resident had a diagnosis of UTI and severe cognitive impairment, and the MDS indicated the resident was not assessed for toileting hygiene due to medical conditions or safety concerns. The resident’s SBAR documented the urinary symptoms, and the physician was notified later that evening. Alert charting showed the resident was still waiting for orders the next day, and the physician’s order to collect urine for UA/C&S was not entered until later that afternoon. The urine specimen required recollection because of incomplete labeling, and a new UA/C&S was collected after that. The physician then ordered Cephalexin for UTI symptoms, but nursing staff later identified that the resident was allergic to penicillin and notified the physician, who discontinued the medication and ordered Macrobid instead. The resident received the first dose of Macrobid nearly three days after the urinary symptoms were first reported. During interviews, an LVN stated she called the physician in the evening and again the next morning but did not know to call the Medical Director when there was no response. An RN stated she made multiple attempts to reach the physician before receiving orders. The DON stated staff should have contacted the Medical Director after one to three unanswered attempts within an hour, and the facility policy required contacting the Medical Director if a timely or appropriate response was not received.
Missing physician orders and qualifying diagnosis for secure unit placement
Penalty
Summary
The facility failed to ensure physician orders were in place for residents admitted to the Alzheimer's certified secure care unit and failed to ensure one resident had a qualifying diagnosis for placement in that unit. Resident #7 had diagnoses including Parkinsonism, dementia, bipolar disorder, Alzheimer's disease with late onset, major depressive disorder, and anxiety, but the physician orders reviewed did not include an order to admit her to the secure care unit. Resident #9 had diagnoses including major depressive disorder, dementia, and anxiety, but likewise had no physician order to admit her to the secure care unit. Resident #44 had dementia and no physician order to admit her to the secure care unit was found in the record. Resident #24 was observed in the 400 hall Alzheimer's secure care unit even though her diagnoses did not include Alzheimer's disease or another related dementia. Her admission MDS showed moderate cognitive impairment, but Section I of the MDS did not indicate Alzheimer's disease or non-Alzheimer's dementia. Her physician orders also did not include an order to admit her to the secure care unit, and her care plan did not address secure unit placement. The report states the DON later obtained a diagnosis for Resident #24 on the day of the interview, but that diagnosis and order had not been obtained before she was placed in the secure unit. Observations showed Resident #7 and Resident #9 in the 100 hall Alzheimer's secure care unit and Resident #24 and Resident #44 in the 400 hall Alzheimer's secure care unit. Interviews with the LVN, ADON, DON, RCN, ADMN, and MD confirmed that residents on the secure units should have physician orders and qualifying diagnoses, and that the admission nurses, nurse managers, ADON, and DON were responsible for obtaining and monitoring those orders. The DON stated the orders for Resident #7, Resident #9, Resident #24, and Resident #44 had not been properly entered into the system, and that Resident #24's qualifying diagnosis and order should have been obtained before admission to the secure unit.
Failure to Obtain Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure Resident #18’s care was adequately supervised by a physician by not obtaining, initiating, or implementing physician orders for weight monitoring despite significant documented changes in nutritional status and body weight. Resident #18 was admitted with chronic respiratory failure, ventilator dependence, and heart failure, and her care plan identified her as having a high BMI related to obesity with interventions to observe, monitor, and report changes, follow physician orders, and monitor weights. Her weight increased from 398.9 lbs to 557.8 lbs over about five months, but there was no documentation of physician notification or orders for daily, weekly, or monthly weights, and no comprehensive assessment or monitoring was documented in response to the change. The record also showed that nutrition assessments dated 10/31/25 and 01/23/26 were identical and did not reflect updated recommendations despite the resident’s ongoing nutritional risks and marked weight gain. A progress note documented a weight of 573 lbs after hospitalization, yet no physician notification or follow-up orders were documented. A later nutrition review noted a BMI of 90 and stated the weight gain required confirmation with daily weights, but there were still no corresponding physician orders, attempts to obtain orders, or weight-monitoring follow-through. CNA #570, LPN #513, and RD #630 confirmed the resident was not on a weight-monitoring list, had no orders for daily, weekly, or monthly weights, and the RD verified no physician orders were present in the medical record.
Failure to Assess and Document a Resident’s Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident’s primary care provider(s) assessed and monitored a Stage 3 sacral pressure ulcer after it was identified by nursing staff and the wound NP. The resident’s medical record showed a new sacral pressure ulcer documented by nursing assessment and a Stage 3 pressure ulcer documented by the wound NP. The resident was then seen multiple times by the primary care MD and the facility NP over the following months, but their progress notes did not identify or assess the pressure ulcer in the physical examination, assessment and plan, or diagnoses sections. The facility policy stated that the attending physician and nursing staff would assess and document significant risk factors for pressure sores and that the physician would evaluate and document wound healing during resident visits, especially for complicated, extensive, or non-healing wounds. During interview, the DON acknowledged that the resident’s primary care provider was responsible for overall care and confirmed the concern that both the MD and NP failed to identify or assess the pressure ulcer during their visits. The NP stated she saw everyone, was one of the resident’s primary care providers, and admitted she had not included the wound in her notes because the wound team was following it.
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