Failure to Clarify Diet Consistency on Admission
Summary
The facility failed to ensure that Resident #473 had physician orders for immediate care consistent with their physical status upon admission. The resident's hospital discharge orders and summary contained conflicting information regarding diet consistency, which was not clarified at the time of admission. The hospital discharge summary indicated the resident had thin liquid dysphagia and required a thickened liquid diet, while the nursing home transfer documented a regular diet. This discrepancy was not addressed, leading to the resident being admitted on a regular diet with thin liquids. During a lunch observation, the resident was found consuming thin liquids, which prompted a visitor to question the appropriateness of the diet. A speech language pathologist intervened and removed the thin liquids, indicating a need to verify the resident's evaluation. The facility's triple check system, which involved the Director of Admissions, Director of Nursing, and Nurse Manager, failed to identify and clarify the conflicting diet information. The Director of Nursing and Nurse Practitioner involved in the admission process did not review the discharge summary thoroughly, missing the dysphagia diagnosis. Interviews with facility staff revealed that the admission process involved reviewing hospital orders and summaries, but the conflicting information was overlooked. The Director of Nursing admitted to not reviewing the discharge summary unless new medications were involved, and the Nurse Practitioner did not recall addressing the diet discrepancy. The failure to clarify the resident's diet consistency upon admission posed a risk of choking or aspiration, which could lead to complications.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident identified as #473 diet order was corrected immediately. Resident #473 has since been discharged to a lower level of care. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All new admissions from the previous three months discharge summaries, and physician orders [REDACTED]. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The policy medication physicians orders management has been updated to include reconciliation of hospital discharge orders with the discharge summary and discrepancies to be clarified by physician order. All nursing staff will be educated on policy revisions and changes. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? A weekly audit of the reconciliations will be completed for three months, followed by monthly for three months and quarterly for six months. All audit results will be reported at QAPI. The date for correction and the title of the person responsible for correction of each deficiency: Director of Nursing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Admission seizure medication orders were not timely processed for a resident with tracheostomy status, epilepsy, and convulsions. The hospital discharge paperwork listed lacosamide, Keppra, and Depakene, but the facility initially had only the AVS and did not enter orders for Keppra or Depakene; lacosamide was entered later. The MAR showed no evidence the resident received Keppra or Depakene, and staff interviews confirmed the missing orders were not fully communicated or processed at admission.
Missed Anticoagulant Orders on Admission: A resident admitted after a suspected CVA with emphysema and cardiomyopathy had hospital discharge orders for apixaban starter pack therapy, but the facility did not ensure the medication was ordered correctly on admission. Review of the MAR showed 4 missed 10 mg doses, and the DON stated the admission nurse transcribed orders while the ADON reviewed them as a second set of eyes.
Failure to Enter Admission Wound Orders: A resident was admitted with surgical wounds and a coccyx pressure ulcer, but the facility did not transcribe the hospital discharge wound orders into the chart at admission and did not obtain an order for the coccyx wound. The wound treatments were not documented as started until several days later, despite staff stating that admission orders should be entered from the discharge paperwork and wound orders obtained when a wound is identified.
Failure to Obtain Immediate Physician Orders for Wounds at Admission: A resident admitted with gangrene, DM2, and osteomyelitis had a recent toe amputation with a surgical wound and a stage II sacral PU, but no wound care orders were in place on admission. The admitting LVN stated she forgot to contact the MD, and the treatment nurse later found no wound care orders when she assessed the resident; orders for the incision and sacrum were not entered until several days later, and no wound care was documented in the interim.
A resident admitted with anxiety, ESRD, and CHF had physician medication orders faxed from the discharging facility before admission, including PRN morphine, lorazepam, and acetaminophen. The facility failed to enter the orders into the clinical record in a timely manner, and the DON confirmed the delay.
A resident was admitted with a PICC line, MDR UTI, and a need for contact isolation, but physician orders for IV meropenem, PICC maintenance, and isolation precautions were not in place until several days later. Staff interviews and record review showed the hospital had reported the resident’s IV therapy and isolation needs at admission, yet the facility did not have the needed orders or signage in place when the resident arrived.
Admission seizure medication orders were not timely processed
Penalty
Summary
Admission medication orders for Resident #80 were not processed in a timely manner after the resident was admitted to the facility with diagnoses including tracheostomy status, unspecified epilepsy, and unspecified convulsions. The resident’s hospital discharge summary dated 06/04/26 listed lacosamide 200 mg twice daily, levetiracetam (Keppra) 2000 mg twice daily, and valproic acid (Depakene) 750 mg three times daily, but the hospital after visit summary did not list those medications on the resident’s medication list. The resident was admitted to the facility at approximately 2:15 P.M., and the physician orders upon admission did not include lacosamide, Keppra, or Depakene on 06/04/26. The resident’s orders later included lacosamide 10 mg/mL, 20 mL via g-tube twice daily on 06/05/26 at 8:12 A.M., but no orders were initiated for Keppra or Depakene. The June 2026 MAR showed no evidence that Keppra or Depakene were administered. Staff interviews confirmed the facility had only the after visit summary at admission, that additional paperwork containing the missing information was later found by an LPN, and that the NP was notified only about the lacosamide order. The DON confirmed the facility was aware of the resident’s seizure diagnoses before admission and stated staff should have notified the NP about the need for orders for Keppra and Depakene.
Missed Anticoagulant Orders on Admission
Penalty
Summary
The facility failed to ensure that physician orders for immediate care were in place at the time of admission for Resident #30, who was admitted from the hospital with diagnoses including emphysema, cerebral infarction, and cardiomyopathy. The resident’s admission record showed a hospitalization for a suspected cardiovascular accident, and the care plan documented that the resident was on anticoagulant therapy and medications were to be administered per the medical doctor’s orders. The hospital discharge orders prescribed apixaban starter pack therapy upon admission, and the manufacturer’s dosing instructions indicated 10 mg twice daily for 7 days followed by 5 mg twice daily. Review of the medication orders and MAR from 6/2/2026 through 6/23/2026 showed the resident was not prescribed apixaban as ordered and missed 4 doses of apixaban 10 mg: the morning dose on 6/3/2026, the morning and evening doses on 6/4/2026, and the morning dose on 6/5/2026. During interview, the DON stated the admission nurse was responsible for transcribing physician admission orders and the ADON reviewed them as a second set of eyes, but the DON was not aware the apixaban had been missed.
Failure to Enter Admission Wound Orders
Penalty
Summary
The facility failed to have physician orders in place for a resident’s immediate care at the time of admission. The resident was admitted with multiple wounds, including surgical wounds to the abdomen and right thigh and a coccyx wound that was present on admission. The hospital discharge paperwork included wound care instructions for the abdominal and thigh wounds, but the facility did not transcribe those discharge orders into the facility physician orders at admission. Record review showed the resident’s wound treatments were not entered into the facility order system until several days after admission. The treatment administration record documented that the abdominal wound, right thigh wound, and another wound treatment were started on 5/5/26, while the resident’s admission and early progress notes showed the wounds were identified on 5/1/26. The coccyx wound was documented on the weekly wound assessment as a Stage II pressure ulcer measuring 3 cm by 2 cm with no depth, pink and yellow wound bed, and no drainage, but there was no treatment order documented for that wound during the initial admission period. Staff interviews confirmed that admission orders were expected to be transcribed from the hospital discharge paperwork and that wound orders should be obtained when a resident had a wound without a treatment order. The admitting nurse, wound nurse, NP, DON, and Administrator all described that the discharge summary or after-visit summary was used for orders and that wound treatment orders should be entered at admission or obtained when a wound was identified. The record also showed the resident had moderately impaired cognition, significant functional dependence, diabetes, heart failure, atrial fibrillation, cancer, depression, and surgical wounds on admission.
Failure to Obtain Immediate Physician Orders for Wounds at Admission
Penalty
Summary
The facility failed to obtain physician orders for the immediate care of Resident #1’s surgical wound and stage II pressure ulcer at admission. Resident #1 was admitted with diagnoses including gangrene of a wound, type II diabetes, and osteomyelitis, and had recently undergone amputation of all toes on the right foot. Record review showed he had a surgical wound from the amputation and a stage II pressure ulcer to the left sacrum noted on the admission assessment, but there were no wound care orders for either wound from the time of admission until 04/06/2026. The MD orders entered on 04/06/2026 included treatment for the right transmetatarsal incision and sacrum, and the MAR/TAR showed no wound care was provided from 04/03/2026 through 04/06/2026. During interview, the admitting LVN stated the resident arrived late on a Friday, department heads were gone, and she forgot to contact the MD regarding the wounds. The treatment nurse stated it was the admitting nurse’s responsibility to complete the initial wound evaluation and call the MD for orders, and that the resident had no wound care orders when she evaluated him on 04/06/2026. The DON and Administrator stated the admitting nurse was responsible for entering orders, completing the admission assessment, notifying the physician, and ensuring needed orders were in the EHR.
Delayed Entry of Admission Medication Orders
Penalty
Summary
The facility failed to ensure physician medication orders were entered into the clinical record upon admission for a resident’s immediate care needs. The resident was admitted with diagnoses including anxiety, end stage renal disease, and congestive heart failure. The discharging facility faxed physician orders to the receiving facility before the resident’s admission time, and those orders included morphine 20 mg/ml, lorazepam, and acetaminophen for as-needed use. However, the facility’s physician orders for the resident lacked evidence that these medication orders were entered into the clinical record in a timely manner. The facility policy entitled Physician Services stated that all orders must be recorded in the resident’s clinical record. During interview, the DON confirmed that the resident’s physician orders were not entered into the clinical record in a timely manner and stated they should have been entered timely. The deficiency involved one resident and was cited under 28 Pa. Code 211.5(f)(i), 211.10(c), and 211.12(d)(1)(2)(3)(5).
Missing Admission Orders for PICC Line and Contact Isolation
Penalty
Summary
The facility failed to ensure that Resident #31 had physician orders for immediate care at the time of admission. Resident #31 was admitted with diagnoses including Klebsiella pneumoniae and a urinary tract infection, and the hospital record showed he had been treated for a multi-drug-resistant organism UTI with IV antibiotics through a PICC line and had been on contact isolation precautions before transfer. The admission MDS also reflected that he had intravenous access, an indwelling urinary catheter, and a multi-drug-resistant organism. Record review and staff interviews showed that the resident arrived with a PICC line and a need for contact isolation precautions, but orders for those needs were not in place until 5/26/2026. The physician orders later entered included contact precautions, meropenem 1 gram IV every 8 hours for 2 weeks, normal saline flushes for the PICC line, monitoring for PICC complications, and securing the PICC line. The resident’s admission report worksheet documented that the hospital RN reported the need for contact isolation precautions and IV meropenem, and nursing notes documented the PICC line on the evening of admission. Staff interviews confirmed that the resident was received as a new admission with a PICC line and a need for isolation precautions, but the facility did not have orders in place for PICC maintenance, antibiotics, or infection control precautions at the time. LVN C stated that on 5/26/2026 she assessed the resident with a PICC line but had no orders to maintain patency, no antibiotics to control the infection, and no contact precautions in place. RN D and LVN B stated they had received report from the hospital and documented the resident’s need for contact isolation, a PICC line, and meropenem, while LVN A stated that standard practice was to secure orders for newly admitted residents to meet their basic immediate needs within 24 hours.
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