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:
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.
A resident with several weeks of itching and self-inflicted scratches to the arms and hands was observed actively scratching with deep scratches present, while documentation showed repeated episodes of pruritus and open skin areas. Nursing staff had previously obtained a short course of Triamcinolone cream and later left messages for the physician requesting systemic medication (cetirizine) and reporting continued scratching and inflamed areas, but no new orders or documented physician response were received despite multiple calls and faxes. This resulted in the resident not being under timely physician supervision or receiving updated treatment in response to ongoing symptoms.
A resident with a g-tube, moderate cognitive impairment, and multiple chronic conditions had care planning and provider orders that did not address several aspects of tube feeding and medication management. The care plan lacked details for actual coccyx skin breakdown, refusal of care, fluid-volume imbalance, HOB elevation timing, and monitoring for hypercalcemia, hypothyroidism, and hyperparathyroidism. Orders also lacked directions for electrolyte monitoring, I&O, fluid balance, medication interactions, adverse-effect monitoring, and when to notify the provider if the resident refused meds or treatments. The PA stated she relied on consultants and pharmacy for monitoring and was unsure of the electrolyte schedule or the nutrition team’s involvement.
A resident admitted after hip fracture repair, who was cognitively intact and full code, developed hypotension, unresponsiveness, and worsening respiratory status over the course of a morning. An LPN contacted a PCP who was not on call and obtained orders for IV fluids while the resident remained unresponsive with abnormal vital signs and escalating oxygen needs. The PCP later stated he did not recall the case, believed he had only been told about low blood pressure, and indicated he would have ordered ER transfer if informed of unconsciousness and respiratory decline. The DON stated that timely sepsis recognition and response is a nursing standard and acknowledged the transfer was not timely, while the facility’s President of Operations reported there was no policy on physician services or supervision. EMS documented a primary impression of sepsis with hypotension, and the death certificate listed sepsis as the cause of death.
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.
Failure to Obtain Timely Physician Response for Ongoing Pruritus and Skin Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician supervised and provided consultation or treatment after being contacted regarding a resident with ongoing pruritus and self-inflicted skin injuries. During an interview and observation, the resident reported itching for about three weeks, stated they had requested medication to help, and was observed scratching both arms, which showed deep scratches on the upper and lower arms. The resident’s care plan documented multiple episodes of self-inflicted scratches to the hands and forearm over several weeks, with interventions directing staff to report abnormalities, failure to heal, and signs and symptoms of infection or maceration to the physician. Record review showed that on 3/27/2026 a verbal order was received to restart scheduled Triamcinolone cream to the right arm and left shin daily for 14 days. A skin/wound note dated 4/5/2026 documented that the resident continued to have pruritus to all extremities, with one open area on the left hand and no signs of infection, and that a message was left for the provider questioning the need for systemic medication (cetirizine) to ease the pruritic issue and assist with sleep. A communication note dated 4/11/2026 documented a call to update the physician that there were no changes to the areas on the arms and legs and that the resident continued to scratch and areas remained inflamed, with staff “waiting on updated orders,” but no physician response or new orders were documented. In interviews, an RN and the DON confirmed there had been a delay in physician response despite multiple calls and faxes and that the physician had not yet responded to the request for treatment for this resident’s ongoing scratching and skin issues.
Failure to Manage G-Tube Care and Medication Monitoring
Penalty
Summary
The facility failed to ensure a physician assistant appropriately managed the care of a resident who required nutrition and hydration via a gastrostomy tube and who had complications related to tube feedings and medication administration through the g-tube. The resident had moderate cognitive impairment, used a walker, and required assistance with several activities of daily living. Her care plan addressed tube feeding and some general skin and incontinence issues, but it did not identify actual skin breakdown on the coccyx, refusal of cares and treatments, risk for fluid-volume imbalance, specific head-of-bed elevation requirements during and after tube feedings, or symptoms and monitoring related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The resident’s orders included Vital Advanced Formula via g-tube, scheduled water flushes, and multiple medications administered through the g-tube, including levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol tartrate, senna, cinacalcet, omeprazole suspension, and ascorbic acid. The physician orders lacked directions for monitoring electrolytes, accurate intake and output, fluid balance related to tube feedings and free water, medication interactions, prevention of adverse effects, ongoing monitoring for nausea, vomiting, and abdominal pain, and when staff should notify the provider if the resident refused medications or treatments. During interviews, the physician assistant stated the resident had a complicated GI tract and hyperparathyroidism causing hypercalcemia, and that symptom management was the primary direction of care because she was no longer a surgical candidate. The physician assistant also stated she did not plan to order follow-up bloodwork because she thought consulting services would monitor electrolytes, was unsure of the electrolyte monitoring schedule, was unsure how involved nutrition services were, and had not directly communicated with the consultant pharmacist about medication timing in relation to tube feedings. Another provider stated facility providers were expected to manage calcium levels after discharge and that medication interactions and administration times should be assessed by the facility provider and pharmacist.
Failure to Provide Adequate Physician Supervision During Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate physician supervision and direction for a resident who experienced a significant change in condition. The resident had been admitted following surgical repair of a hip fracture and was documented on the admission MDS as cognitively intact, fully oriented, and able to communicate needs, with a full code status. On the night before the event, the resident’s vital signs and neurological status were documented as stable, with no physical concerns noted. On the following morning, the resident developed hypotension, first identified around 6:27 a.m., when the weekend on‑call provider was contacted and ordered holding aspirin and antihypertensives, testing stool for blood, and hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had further declined, he was unresponsive to verbal stimuli, and his oxygen saturation was low on room air. Throughout the morning, nursing documentation showed that the resident remained unresponsive, with persistent hypotension, tachycardia, and declining respiratory status requiring escalating oxygen support. The LPN caring for the resident contacted the resident’s PCP, who was not on call, and obtained orders for IV fluids at 100 ml/hr and later additional IV fluids, which were implemented while the resident’s unresponsiveness and abnormal vital signs continued. The PCP reported that he did not recall the resident or the specific calls but stated he was not on call that day and believed he was likely only informed about low blood pressure, not about unresponsiveness or declining respiratory status. He stated that if he had known the resident was unconscious with worsening respiratory status, he would have ordered immediate transfer to the ER. The DON stated that sepsis recognition and rapid response are a nursing standard in the facility and acknowledged it would be very hard to say the resident was transferred in a timely manner. The facility’s President of Operations reported that the facility did not have a policy regarding physician services or supervision. EMS records later documented a primary impression of sepsis with hypotension, and the resident’s death certificate listed sepsis as the cause of death.
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