Lack of Physician Orders for Dialysis in Resident's Care Plan
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, specifically for a resident undergoing dialysis. The resident, who was diagnosed with End Stage Renal Disease and Coronary Artery Disease, did not have documented physician orders for dialysis, including the frequency and monitoring of the permcath. Despite the resident's care plan indicating the need for hemodialysis, there was no evidence of physician orders to support this treatment. Observations and interviews revealed that the resident was alert and oriented, and regularly attended dialysis sessions. However, the facility's documentation did not reflect this, as there were no physician orders in the system for the resident's dialysis schedule. The facility's policy required medication order reconciliation during admissions and routine reviews, but this was not adhered to in the case of the resident's readmission. Interviews with facility staff, including a CNA, RN Manager, and the Director of Nursing, indicated that the omission of the dialysis order was an error during the resident's readmission process. The staff were aware of the resident's dialysis schedule, but the necessary orders were not documented in the system. The Medical Doctor confirmed that the resident was stable and that the omission was likely an oversight during the readmission process.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F711 Corrective Actions for Residents Identified: Resident # 71 was seen by an attending physician on 12/19/2024. During the visit, the resident's total program of care, including medications and treatments, was reviewed and documented. Resident # 71 received [MEDICAL TREATMENT] without interruption of services; Resident # 71 had an order placed immediately. The Care Plan was initiated on 8/19/2024 and has been reviewed and updated for [MEDICAL TREATMENT]. Element 2 Residents at Risk: All Residents receiving [MEDICAL TREATMENT] have the potential to be affected by this practice. A list of current residents receiving [MEDICAL TREATMENT] in the past three months was obtained, and the Medical Record was audited to ensure that all physician orders [REDACTED]. No Other issues were identified. Audit tool was developed to monitor compliance. Element 3 Systemic Changes: Policy and Procedure for physician's orders [REDACTED]. All Registered Nurses are being educated on the importance of timely physician visits, documentation review, and order accuracy. The nursing supervisor will review care notes weekly to ensure all visits and orders are correctly documented. An audit tool was created to confirm that all physician orders [REDACTED]. Element 4 Quality assurance Monitoring: Conduct weekly audits for 90 days to ensure compliance with physician visits, regulations, care note reviews, and orders. Findings will be reported to the administrator monthly, and any negative findings will be corrected immediately. On a quarterly basis, x 3 quarters ADNS or designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Element 5: Persons Responsible: Completion Date: (MONTH) 12, 2025 Director of Nursing Services: Oversee the P(NAME) implementation and staff education. Medical Director: Collaborate with physicians to ensure timely visits and documentation.
Penalty
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The facility failed to ensure that Psychiatry Group progress notes were available for continuity of care for a resident with schizophrenia who received outpatient mental health services. The resident said he attended therapy every three months for medication and care, but the clinical record contained no progress notes or other documentation from the outside provider. The DON contacted the clinic, which said a signed release was needed before records could be sent, and the ADON later confirmed no documentation had been received.
Delayed and inaccurate physician documentation affected two residents. An NP and attending physician did not enter progress notes, H&Ps, and orders into the chart in a timely manner after seeing a resident, and some notes were not available for staff review until days later. The record for one resident also showed conflicting documentation about a Seroquel GDR, with the NP and attending continuing to chart the admission dose despite the GDR being completed.
Physician Block Orders Not Signed During Required Visits: A resident’s provider completed progress notes during multiple required regulatory visits, but the physician block orders for meds and tx were not signed on the visit dates. The orders were signed days later after each visit, and the DON confirmed the finding during interview.
A provider failed to review and revise a resident’s care after a urology consult for urinary retention. The consult noted the resident could not communicate voids, had dry diapers on assessment, and raised concern for silent retention, with a plan for bladder scans and continued straight catheterization per policy. A later provider note mentioned monitoring for UTI or retention symptoms and using bladder scans for discomfort or poor voiding, but did not address the straight catheterization recommendation. The DON stated the facility did not have a bladder scan machine and used bladder ultrasounds instead.
A resident with AFib, DM, and HF was receiving Warfarin and had orders for PT/INR monitoring plus multiple additional labs. The record showed the ordered labs were not completed, there was no documented notification to the MD or RN supervisor, and there was no documented follow-up by the MD on the missing lab work.
A physician telephone order for Tylenol suppository 240 mg was given for an infant resident but was not written, signed, or dated by the MD. The dose was administered after the parent requested medication for irritability, and the next morning the resident had vomiting and increased sleepiness; the NP noted the dose exceeded the loading dose for age and weight, Poison Control was contacted, and the resident was sent to the ER for evaluation.
Missing Psychiatry Progress Notes for Resident Mental Health Care
Penalty
Summary
The facility failed to ensure that the Psychiatry Group provided progress notes for continuity of care with each visit for one resident with schizophrenia. Review of the resident’s MDS dated 6/3/26 showed a diagnosis of schizophrenia, and the clinical record indicated the resident used an outside mental health provider for psychiatric care. During an interview on 7/21/26, the resident stated he went to outpatient therapy every three months for care and medication and had no issues obtaining his mental health medication. Review of the resident’s clinical record did not identify any progress notes or other documentation from the outpatient therapy providers related to continuity of care. The DON stated on 7/21/26 that she called the clinic and left a message with Medical Records, and the clinic later stated the facility needed the resident to sign a release form before records could be sent, even though he was a resident of the facility. The DON then had the form faxed and planned to have it signed by the resident, and the ADON later stated the clinic did not send any documentation.
Delayed and Inaccurate Physician Documentation
Penalty
Summary
Physicians and the nurse practitioner failed to have progress notes, history and physicals, and orders entered into the medical record in a timely manner after seeing residents, and the documentation did not always reflect the most accurate resident information. For Resident #9, NP #27 visited on 4/14/26 and discussed with the power of attorney the plan for a below-the-knee amputation, but the note was not available in the record until 4/18/26. For Resident #1, multiple hospitalizations required new history and physicals on each readmission, but several notes were initiated and posted more than 24 hours after the resident was seen and orders were reviewed. An admission note initiated on 5/14/26 with an effective date of 5/15/26 was not available until 5/17/26, and another admission note from 6/23/26 was not signed or available until 6/25/26. Additional attending physician notes dated 7/2/26 and 7/5/26 were not available until 7/10/26. The record also showed a gradual dose reduction for Seroquel completed on admission in fall 2025, while both NP #27 and Attending #28 continued to document that Resident #1 remained on the admission dose from August 2025 through January 2026.
Physician Block Orders Not Signed During Required Regulatory Visits
Penalty
Summary
The facility failed to ensure that the resident’s doctor reviewed the resident’s total program of care during required regulatory visits and signed the physician block orders for medications and treatments at the time of those visits. Record review showed that a required regulatory visit was completed on 12/9/25, with a provider progress note documented that day, but there was no evidence that the physician block order was signed on the day of the visit. The facility was unable to provide evidence that the order was signed on that date, and the physician block orders were not signed until 1/12/26, 34 days later. The same issue occurred during subsequent required regulatory visits on 2/12/26, 4/14/26, and 6/4/26. Each visit had a provider progress note completed on the visit date, but there was no evidence that the physician block order was signed on the day of the visit. The facility could not provide evidence of same-day signing, and the physician block orders were signed later on 3/8/26, 5/4/26, and 6/29/26, respectively. On 7/21/26 at 12:05 p.m., the DON confirmed the finding during interview.
Provider Did Not Address Urology Recommendations for Urinary Retention
Penalty
Summary
The primary medical provider failed to review and revise Resident #28’s total program of care after a urology consult addressed urinary retention. The resident was observed near the nurses’ station on multiple days, with staff using a communication board to communicate with the resident. On 7/15/26, the medical record was reviewed and showed that the resident had been seen by a urology consultant on 6/29/26 for urinary retention. The consult note stated urinary retention had been noted at the hospital, the resident was unable to communicate voids, diapers were dry on assessment, and silent retention was a concern. The plan included checking bladder scans for post void residual at reasonable intervals to establish a trend and continuing straight catheterization for urinary retention per facility policy. A provider progress note dated 7/13/26 documented that urology had noted no acute concern for retention and recommended monitoring UTI or retention symptoms, and it stated to use bladder scan for discomfort or poor voiding and trend volumes. However, the note did not acknowledge the consult recommendation for straight catheterization for retention. During interview, the DON stated the facility did not have a bladder scan machine and would not be able to provide the recommendation, and that the facility used bladder ultrasounds if retention needed to be evaluated. When asked whether the provider should have contacted urology for an alternative plan if resources were not available, the DON confirmed that would be her expectation.
Physician Did Not Follow Up on Ordered Labs for Resident on Warfarin
Penalty
Summary
The facility did not ensure that the physician reviewed the resident’s total program of care, including medications and treatments, at the required visits. This was identified for one resident who had diagnoses including atrial fibrillation, diabetes mellitus, and heart failure, and whose MDS documented intact cognition and anticoagulant use. The resident was discharged from the hospital on Warfarin, and the physician ordered Warfarin therapy along with monitoring for signs and symptoms of bleeding and laboratory follow-up for Prothrombin Time/International Normalized Ratio testing. The physician also ordered multiple laboratory tests on 03/18/2026, including PT/INR, PTT, CD4 and CD8 counts, renal and liver function tests, Hemoglobin A1c, thyroid studies, lipid panel, CBC with differential, platelet count, urinalysis, hepatitis testing, and other labs. The record showed no documented evidence that these laboratory tests were performed, and there was no documented evidence that the physician or the RN supervisor were notified that the tests were not done. A nursing note later documented the PT/INR-related order, but the medical notes reviewed from 03/18/2026 through 04/24/2026 contained no documented evidence that the physician followed up on the ordered laboratory tests. Facility policies stated that residents receiving anticoagulation therapy should have labs drawn as ordered to determine effectiveness of therapy, that nurses should assess and document recent labs and therapeutic dose monitoring, and that abnormal lab results should be reported to the HCP and documented. During interview, the Medical Director stated that monitoring depends on the clinician, that nursing should have notified the physician that the labs were not done, and that the physician should have followed up. The Medical Director also stated they were not aware the resident’s labs were not performed.
Unsigned Telephone Order for Tylenol Given to Infant Resident
Penalty
Summary
The facility failed to ensure that the physician wrote, signed, and dated a telephone order for Tylenol suppository 240 mg that was given to an infant resident. The resident was a 7-month-old premature infant admitted with diagnoses including pulmonary hypertension of newborn, feeding difficulties, interstitial pulmonary disease, congenital hypotonia, and other neonatal conditions. A nursing note documented that the resident’s parent requested Tylenol for irritability after a vaccine, and the attending physician was called and gave a telephone order for Tylenol suppository 240 mg rectally, which was administered at 9:30 PM. The record showed no evidence that the attending physician wrote, signed, or dated the telephone order. The facility policy required telephone orders to be documented, read back for verification, and authenticated by the ordering practitioner. The physician later stated they gave the order by telephone, were thinking of another resident’s dosage, did not recall the nurse reading back the dosage, and did not enter or sign the order because they did not have access to a computer. The next morning, the resident’s parent reported vomiting and increased sleepiness, and the nurse practitioner was notified that the resident had received 240 mg rectally. The nurse practitioner documented that the dose exceeded the Tylenol loading dose for the resident’s age and weight, contacted Poison Control, and the resident was transferred to the emergency room for evaluation. The hospital discharge summary documented no abnormal findings, and the emergency department noted low concern for acute Tylenol toxicity given the amount and route administered.
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