Failure to Address Significant Weight Loss in Resident
Summary
The facility failed to ensure adequate physician supervision of medical care for a resident who experienced a significant weight loss of 41 pounds, or 28.12%, over a period of sixteen weeks. Despite the facility's policy requiring that significant weight changes be monitored and addressed by the interdisciplinary team, including notification to the attending physician, there was no documented assessment or intervention by the physician regarding the resident's weight loss. The resident, diagnosed with Huntington's Disease, Parkinson's Disease, and Gastritis, required assistance with eating and had a history of poor intake, yet the physician did not document any medical note or implement appropriate interventions in response to the weight loss. Observations and interviews revealed that the resident's weight was not consistently documented in physician or nurse practitioner progress notes, and there was a lack of communication between the dietary staff and the physician regarding the resident's nutritional status. The registered dietician noted the resident's malnourished status and poor intake but had not formally discussed the weight loss with the physician. The nurse practitioner and director of nursing were unaware of the resident's significant weight loss, indicating a breakdown in communication and monitoring processes within the facility. The resident was observed multiple times not consuming meals, with little to no staff assistance or encouragement provided during mealtimes. Despite the resident's poor intake and significant weight loss, the facility's staff did not adequately address the issue or implement effective interventions to prevent further decline. The lack of physician involvement and oversight, combined with insufficient staff support during meals, contributed to the deficiency in care for the resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with ESRD on hemodialysis, diabetes, and severe malnutrition developed moisture-associated skin damage to the sacrum and buttocks, for which topical treatment was ordered but not clinically reassessed or documented for effectiveness over an extended period, despite later evidence of wound deterioration. After a hospital stay, the resident was readmitted with eight documented wounds, including a Stage III sacral ulcer, bilateral hip wounds, heel injuries, gangrenous toes, and a left bunion wound. On readmission, nursing documented multiple wounds, but the physician history and physical noted only sacral moisture-associated skin damage, and a debriding agent was ordered without specifying the body site. A wound nurse assessment documented findings that did not match the hospital discharge summary or nursing admission note, and subsequent orders addressed only sacral dermatitis and a left hip abrasion, with no documented physician orders, assessments, or treatments for the right hip wound, left bunion wound, or gangrenous toes, and no podiatry consult. The wound PA later assessed only selected areas directed by the wound nurse, while the readmitting MD, attending MD, and medical director each acknowledged limited or no direct examination of the resident and incomplete follow-through on the documented wounds, resulting in a failure of effective physician supervision of medical care.
A resident with osteomyelitis and multiple stage 4 pressure ulcers of the sacrum, ischium, and hip, who was on hospice and had detailed wound care orders in place, did not have documented routine examinations of these wounds by a licensed medical provider. Wound assessments showed stalled and improving wounds with undermining and tunneling, and an LPN reported that hospice directed treatments focused on comfort and infection control. However, review of progress notes over many months, along with a physician note and a hospice NP face-to-face encounter, showed references to decubitus and non-healing stage 4 ulcers but no documentation that the pressure ulcers were actually examined by a provider, resulting in the cited deficiency.
A resident with diabetes, gangrene, and recent left BKA experienced several days of abdominal pain, nausea, vomiting, and diarrhea, with care plans directing close monitoring and physician notification for changes in condition. The attending physician ordered imaging and labs, but critical lab results, including an elevated WBC, were not reported and remained pending in the EHR. On the day of the event, the resident’s blood glucose rose from the 470s to over 560 mg/dL despite multiple insulin orders and administrations, with the LVN failing to document exact times of blood glucose checks and insulin doses. As the resident became clammy, lethargic, and then unresponsive with HR 194, staff reported making multiple unsuccessful attempts to reach the attending physician and NP, who was out of town and had no alternate physician designated. The DON then instructed staff to call 911, and the resident was sent to the ED, where she arrived unresponsive and later died. Surveyors found that the facility failed to ensure another physician supervised the resident’s care when the attending was unavailable and failed to ensure critical lab values and worsening condition were reported and addressed.
A resident with diabetes, cellulitis, severe cognitive impairment, and a chronic right lower leg venous ulcer experienced documented worsening of the wound from mixed granulation/slough to 100% slough/necrotic tissue with heavy drainage and severe pain. The WD recommended hospital admission for operative debridement and possible leg amputation, and the WN documented this recommendation and the resident’s pain, but the MD did not review the wound documentation, did not personally reassess the wound, and chose not to send the resident to the hospital at that time. Instead, the MD gave a verbal order for a vascular surgery consult that was not entered into the record for five days, during which only two attempts were made to obtain consent from the responsible party. The resident later showed signs of acute decline, including hypotension, tachypnea, altered responsiveness, and refusal of medications and food, and was ultimately hospitalized with septic shock related to right lower extremity cellulitis and later died; this sequence of events formed the basis of the deficiency for failure of effective physician oversight and timely medical intervention.
A resident with iron deficiency anemia and diabetes had a consultant appointment where epoetin alfa was recommended once weekly to support red blood cell production. The consultant’s recommendation was not documented as being reviewed with the physician for an extended period, and this delay in physician involvement in the resident’s care was confirmed by the Regional Clinical Director. This constituted a failure to ensure timely physician supervision of care as required by regulation.
A resident with chronic pain syndrome had scheduled morphine IR 15 mg ordered four times daily, but multiple doses were missed when the medication ran out and was not available. Nursing staff contacted the on-call NP and pharmacy several times, but the NP did not resend the prescription that evening, did not order alternative pain management, and did not direct monitoring for withdrawal or increased pain. The resident reported severe pain, decreased mobility, poor appetite, and increased anxiety during the period without scheduled morphine. The pharmacy later confirmed it had not received the NP’s prescription that night and stated that an emergency verbal order process existed and that the lack of medication constituted an omission medication error, while facility policy required timely practitioner orders and 24-hour physician services for immediate care needs.
Failure of Physician Supervision and Wound Management for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical care was effectively supervised by a physician, in accordance with facility policy and regulatory requirements. The resident had multiple serious comorbidities, including end stage renal disease on hemodialysis, diabetes mellitus, and protein calorie malnutrition, and was assessed as having moderately impaired cognition and a moderate risk for pressure injury. Initially, the resident had no documented skin problems, but on 08/12/2025 an RN requested a wound care consultation without documenting an identified wound or notifying the attending physician. No wound assessment was documented until 08/14/2025, when the wound care nurse identified moisture associated dermatitis to the sacrum and bilateral buttocks and a physician ordered topical treatments for 30 days. Although a subsequent nursing note on 08/15/2025 documented skin openings to the bilateral buttocks and indicated that the wound nurse and physician were to evaluate, there was no documented evidence of wound progression, effectiveness of treatment, or clinical reassessment between 08/14/2025 and 11/29/2025, despite a later surgical note on 12/17/2025 describing a sacral wound with serosanguinous exudate and specific measurements. After the resident was transferred to the hospital and later discharged back to the facility, the hospital discharge record documented eight wounds, including a Stage III sacral ulcer, unstageable and deep tissue injuries to both hips, deep tissue injuries to both heels, dry gangrene of the left toe, a necrotic right great toe, gangrene of all toes, and a left bunion with partial thickness skin loss. On readmission, the facility nurse documented pressure wounds to the sacrum, bilateral hips, gangrene to all toes, and bilateral heels, but the physician’s history and physical documented only moisture associated skin damage to the sacrum and did not identify the Stage III sacral ulcer or the other seven wounds listed in the hospital discharge summary. A physician order for collagenase was written without specifying the body site, and the treatment administration record showed the treatment as given on two days without identifying where it was applied. The wound care nurse’s assessment on 01/05/2026 documented only a right hip superficial abrasion, moisture associated dermatitis to the sacrum, and unremarkable lower extremities and heels, which did not correlate with the hospital discharge assessment or the nurse’s admission/readmission note. Subsequent physician orders on 01/05/2026 addressed Medi-honey treatment for irritant contact dermatitis and Triad cream for a left hip abrasion, but there was no documented evidence of physician orders or treatment for four of the wounds: the right hip wound, left bunion partial thickness skin loss, and bilateral gangrenous toes. There was also no documented evidence of a podiatry consultation. The wound care physician assistant later documented assessments of the sacrum and left hip (identified as a Kennedy terminal ulcer) but did not assess the gangrenous toes or left bunion wound, stating they only examined areas directed by the wound care nurse. The readmitting physician stated they reviewed the hospital discharge record and saw moisture associated skin dermatitis but did not observe the hip wounds, attempted but did not document a refused lower extremity exam, and did not order podiatry because they did not assess the bandaged extremities. The attending physician for the unit reported never seeing the resident after readmission and was unaware of the multiple wounds and gangrenous toes, relying on the wound care team and unit nurses for communication. The medical director acknowledged reviewing the hospital discharge notes and seeing the list of wounds, stated that the readmitting physician should have ordered treatments for all wounds, and confirmed they did not physically examine the resident. Collectively, these documented omissions and incomplete assessments demonstrate that the resident’s medical care, particularly wound management, was not effectively supervised by a physician as required by facility policy and regulation.
Failure to Ensure Provider Examination of Stage 4 Pressure Ulcers for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed medical provider routinely examined a resident’s stage 4 pressure ulcers, despite the resident being under hospice care and having multiple complex wounds. The resident was admitted and later readmitted with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, and stage 4 pressure ulcers of the sacral region, right buttock, and left buttock. The resident’s MDS showed moderate cognitive impairment and four stage 4 pressure ulcers, two of which were present on admission or reentry. Wound assessments dated 3/11/26 documented stage 4 pressure ulcers on the left and right ischium, sacrum, and left rear hip, with some wounds described as stalled and others improving, and with undermining and tunneling present. Physician orders were in place for specific wound care treatments, including cleansing, packing, and application of Dakins-moistened gauze and foam dressings. During the survey, the wound care LPN reported that the resident was receiving hospice services and that hospice directed the wound treatments, focusing on comfort and infection control rather than healing. However, review of the resident’s progress notes from 5/1/25 through 3/12/26 did not show documentation that a provider had examined the resident’s stage 4 pressure ulcers during that period. When the surveyor requested the most recent date a provider evaluated the wounds, the facility produced a physician progress note from 6/26/25 and a hospice NP face-to-face encounter note from 2/28/26. Both documents referenced the presence of decubitus ulcers and non-healing stage 4 pressure ulcers, but neither documented an actual examination of the pressure ulcers. This lack of documented provider examination of the resident’s stage 4 pressure ulcers led to the cited deficiency.
Failure to Ensure Physician Coverage and Response to Critical Labs and Hyperglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure that another physician supervised the medical care of a resident when the attending physician was unavailable, and to appropriately act on critical clinical information and worsening condition. The resident was admitted from an acute hospital with diagnoses including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, gangrene, and a recent left below-knee amputation. The care plan identified diabetes management, infection related to gangrene, and significant pain management needs, with instructions to monitor and report changes in mental status, behavior, appetite, and pain, as well as signs and symptoms of infection and adverse reactions to analgesics. The resident had been complaining of abdominal pain, nausea, vomiting, and diarrhea over several days, and the attending physician ordered a KUB, abdominal ultrasound, and labs, including amylase and lipase. Radiology reports for the KUB and abdominal ultrasound showed no acute process and no bowel obstruction or ileus, and these results were reported to the physician and NP. However, critical lab values, including an elevated WBC indicating possible sepsis, were received on a prior date and remained pending review in the electronic record, meaning they were not reported to the attending physician or NP. The attending physician later stated that if he had known about these lab results, he would have sent the resident to the hospital, and that the critical WBC and rising blood glucose indicated the resident was acutely ill and going into full sepsis. The resident continued to complain of abdominal pain and had poor appetite, and the physician documented follow-up visits and ordered medications such as Bentyl and Zofran PRN, but there is no documentation that the critical lab values were communicated to him or that he was notified of ongoing ineffective pain control or persistent abdominal symptoms over the days in question. On the day of the acute event, the resident’s family checked the resident’s blood glucose with their own glucometer and obtained a reading of approximately 470–495 mg/dL. The LVN notified the RN weekend supervisor and the attending physician, who ordered initiation of a moderate sliding scale insulin regimen, blood glucose checks AC and HS, and 10 units of Lantus. After 10 units of Lispro were given, a recheck about 45 minutes later showed the blood glucose had increased to 517 mg/dL. The LVN reported this to the physician, who then ordered discontinuation of the moderate sliding scale, initiation of a high sliding scale, administration of 14 units of Lispro STAT, and 10 units of Lantus STAT. The LVN did not document the exact times of the blood glucose checks or insulin administrations, although he acknowledged being trained to do so. The facility did not have Lantus in the insulin E-kit, and the RN supervisor borrowed a vial from another resident. Later that afternoon, the resident’s blood glucose was rechecked and found to be 563 mg/dL. The LVN reported that the resident became clammy, increasingly lethargic, and then unresponsive, with a heart rate of 194 and fixed pupils. Multiple attempts were made by the LVN and weekend supervisor to contact the attending physician and NP by phone and group text, but they reported receiving no response. The DON confirmed that the attending physician, who was also the medical director, was out of town on vacation and that the NP assigned to the facility did not answer calls or texts. The DON instructed the nurse to call 911 and send the resident to the ER due to the change in condition. EMS was activated, and the resident was transported to the hospital, where she arrived unresponsive with a blood glucose of 561 mg/dL, hypotension, hypoxia, and required CPR and intubation. Despite resuscitation efforts, the resident expired in the ED. The attending physician later denied receiving calls or texts on the day of the event and stated that he and his NPs were always available and that he did not see a need for an alternate physician when he was out of town. The facility was unable to provide a policy and procedure on physician services to the surveyor prior to exit. The surveyor concluded that the facility failed to ensure another physician was available to supervise the medical care of the resident when the attending physician was unavailable and failed to ensure that critical lab values and ongoing changes in condition were reported and acted upon. This failure occurred for one resident reviewed for physician services and was associated with the resident’s continued worsening condition, severe hyperglycemia, unresponsiveness, transfer to the hospital, and subsequent death. The report states that this failure could place residents at risk of delayed treatment or intervention, decline in health, and/or death.
Failure of Physician Oversight and Timely Response to Worsening Venous Leg Ulcer
Penalty
Summary
The deficiency involves the failure of the Medical Director/attending physician to effectively oversee, supervise, and assess a resident’s medical care in relation to a worsening right lower leg venous stasis ulcer. The resident was admitted with diagnoses including a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, and had severe cognitive impairment with a responsible party designated for decision‑making. An order was in place for wound evaluation and treatment by an outside wound care company, and weekly skin assessments documented the wound’s status. On one weekly assessment, the wound nurse documented that the right lower leg venous ulcer measured approximately 15 cm x 5 cm x 0.4 cm post‑debridement, with 50% slough and 50% granulation tissue, significant drainage, no odor, no signs or symptoms of infection, and that the wound was showing improvement. On a subsequent weekly assessment, the wound nurse documented that the same wound was worse, with the same measurements but now 100% slough/necrotic tissue and heavy drainage, though still noted as having no odor and no signs or symptoms of infection. During wound rounds on that later date, the wound doctor evaluated the resident’s right lower leg ulcer, determined that bedside wound care was not effective, and recommended hospital admission for operative debridement and possible above‑ and below‑knee amputation. The wound nurse later entered a progress note reflecting that the wound was worsening, had 100% slough/necrotic tissue, heavy drainage, and that the resident was in excruciating pain despite pre‑medication; this note was entered with a later date but described the earlier wound‑rounds encounter, and the nurse acknowledged she did not label it as a late entry to avoid it being flagged. The care plan for skin integrity was updated to include the wound doctor’s recommendation for hospital admission for operative debridement and possible leg amputation. The Medical Director stated that the wound doctor informed him of serious concern about the resident’s non‑healing venous ulcer, significant vascular compromise, and the need for hospitalization and evaluation by a vascular surgeon. The Medical Director reported that he gave a verbal order to the wound nurse for a vascular surgery consult and expected it to be carried out by the following day, but he did not send the resident to the hospital at that time because he did not feel it was urgent and had not reviewed the wound doctor’s notes or the documented deterioration of the wound. The order for the vascular consult was not entered into the medical record until five days after the verbal order, and the DON confirmed that only two attempts were made to obtain consent from the responsible party for the vascular consult during that period. The Medical Director also acknowledged that he did not assess the resident’s right leg ulcer after the wound doctor’s recommendation and could not recall the last time he personally assessed the wound, stating he had not gone out of his way to observe it because the facility had a wound team. Subsequently, the resident experienced a change in condition, with documentation by the wound nurse of low blood pressure (79/42), elevated respirations (30), slightly elevated temperature (99.6°F), non‑responsiveness compared to baseline, refusal of medications, refusal of breakfast, no fluid intake, facial grimacing with moaning, and refusal of pain medication. The resident was later sent to the hospital, where records showed presentation to the ED with confusion, increased heart rate, and low blood pressure due to septic shock related to cellulitis of the right lower extremity. Hospital findings included markedly elevated WBC, elevated lactic acid, CT evidence of a large soft tissue defect with fluid collection extending to the lateral ankle and forefoot muscles, and positive blood cultures for multiple bacteria. The resident was admitted to the ICU, later placed on comfort measures only, and died with causes listed as cardio‑pulmonary arrest, septic shock, and necrotizing fasciitis. Facility documents describing the Medical Director’s duties included coordinating medical care, participating in patient care review and infection control, being responsible for reviewing and evaluating patient care services, and making skin and high‑risk patient rounds, which contrasted with the Medical Director’s statements that he had not reviewed the wound documentation or assessed the wound after the wound doctor’s urgent recommendation.
Failure to Timely Communicate Consultant Medication Recommendation to Physician
Penalty
Summary
The facility failed to ensure timely physician supervision of care for one of 14 sampled residents when a consultant’s medication recommendation was not promptly communicated to the attending physician. The resident had diagnoses including iron deficiency anemia and diabetes. On January 13, 2026, a consultant documented a recommendation that the resident receive epoetin alfa once every seven days to help produce red blood cells. Clinical record review showed no documented evidence that this recommendation was reviewed with or acted upon by the physician until March 4, 2026. In an interview on March 5, 2026, at 9:15 a.m., the Regional Clinical Director confirmed that the consultant’s recommendation had not been reviewed with the physician in a timely manner, resulting in noncompliance with physician supervision requirements under 42 CFR 483.30(a) and 28 Pa. Code 211.2(d)(3). This deficiency was previously cited on July 3, 2025, under the same regulatory requirements for physician supervision and medical director responsibilities.
Failure to Obtain Timely Practitioner Orders and Morphine Refill for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely practitioner orders and provision of prescribed narcotic pain medication when a resident’s scheduled morphine was not available. The resident had an order dated 11/28/23 for morphine IR 15 mg to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. The February 2026 MAR showed that on 2/2/26 the 4:00 p.m. and 8:00 p.m. scheduled doses were not administered because the medication was not available, and only a single 7.5 mg PRN dose was given at 5:03 p.m. On 2/3/26, the 6:30 a.m. scheduled dose was not administered and the 11:30 a.m. dose was given late at 1:36 p.m., again due to unavailability of the ordered morphine. Progress notes and interviews documented repeated but unsuccessful efforts by nursing staff to obtain a new prescription and supply of morphine. On the evening of 2/2/26, staff contacted the on-call provider and pharmacy multiple times and documented that the medication was not available. The nurse practitioner reported she had sent the morphine prescription to the pharmacy at 7:00 p.m., but the pharmacy could not locate it, and she declined to fax or resend the prescription that night, stating she might do so the following morning. She did not provide alternative pain management orders, did not give instructions to monitor for opioid withdrawal symptoms, and did not direct staff on how to address increased pain. The charge RN confirmed she attempted to reach the NP multiple times between mid-afternoon and late evening, could not use the MAR reorder function because a new prescription was required, and identified the failure to obtain a timely prescription as the root cause of the missed doses. The resident reported that after running out of morphine in the afternoon, he did not receive his scheduled doses for almost a full day, during which he experienced pain rated 10/10, inability to get out of bed, decreased appetite, and worsened anxiety with difficulty swallowing. The pharmacist stated the pharmacy did not receive a morphine prescription from the NP on 2/2/26 and only received a new prescription from a certified physician assistant the following day, which included authorization to obtain a dose from the e-kit. The pharmacist explained that after-hours procedures allowed for emergency verbal prescriptions for controlled substances and characterized the lack of medication in this situation as an omission medication error. The facility’s Physician Services policy required that a physician, NP, or PA provide orders for residents’ immediate care needs, ensure 24-hour availability of physician services in case of emergency, and maintain residents under physician care with timely communication and documentation of orders, which was not met in this case when timely orders and medication were not secured for the resident’s pain management.
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