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:
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 medication orders were not accurately reconciled for a resident after hospital discharge. The resident received an incorrect Carvedilol dose, Divalproex was given at the wrong interval, and a new Voltaren gel order was not transcribed or administered. The NP confirmed the meds were not reviewed with a provider or reconciled on readmission, and the DON confirmed the findings.
Delayed Reconciliation of Admission Antibiotic Order: A resident admitted from a GACH had an antibiotic order for vancomycin omitted from the initial admission reconciliation. The DON and RN stated the admitting nurse was responsible for reconciling hospital orders, but the vancomycin oral suspension was not entered until the next day, with the first dose given later that evening; the medication was not stocked in the ADC.
Missing admission orders for morphine and foley catheter care. A resident with hospice-related comfort care had morphine orders entered without specific pain-level parameters, and an LVN stated the order was entered from a hospice order but lacked the details nurses needed to dose it correctly. Another resident with an indwelling catheter had catheter care documented in the care plan, but the chart initially had no catheter orders; staff later entered catheter-related orders after the omission was identified.
A resident with schizophrenia, bipolar disorder, and dysphagia was admitted and readmitted multiple times without the facility completing required comprehensive admission/readmission evaluations or verifying diet orders against prior records and swallowing needs. Initial and subsequent documentation showed inconsistent diet specifications (mechanical soft with nectar thick liquids vs. mechanical soft with thin liquids), with no evidence that staff contacted the hospital or prior group home to confirm the resident’s established puree/nectar thick diet. Required sections of the RD’s nutrition evaluation regarding prior therapeutic diet and familiarity with mechanically altered diets were left blank, and an admission evaluation was not completed after one readmission, while the existing diet order remained active without reassessment. Later, an IDT conference and SLP evaluation identified oral dysphagia and confirmed the resident’s prior puree/nectar thick regimen, underscoring that earlier diet orders and assessments had not been verified or aligned with the resident’s known swallowing deficits.
A resident admitted after a femur fracture had hospital discharge paperwork that included staple removal instructions and an order for Lovenox 30 mg BID for 21 days, but the facility failed to transcribe the anticoagulant into the MAR. The WCC reported the staples were not removed because the PCP wanted the surgeon to remove them, and the conversation about that decision was not documented.
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.
Admission Medication Orders Were Not Reconciled
Penalty
Summary
The facility failed to ensure physician orders at admission were accurate for one resident reviewed for admission orders. The resident was discharged from the hospital on 5/9/26, but the discharge summary was not reviewed with the physician on call. The hospital discharge summary showed that Carvedilol was changed from 25 mg to 12.5 mg twice daily, Voltaren 1% gel was newly ordered for the lower back twice daily, and Divalproex was changed from three times daily to every 8 hours. Review of the May 2026 MAR showed the resident received Carvedilol 25 mg from 5/9/26 through 5/12/26 for six doses, Divalproex was administered at 8 a.m., 2 p.m., and 8 p.m. from 5/9/26 through 5/12/26 with only 6 hours between doses, and no new order was transcribed or administered for Voltaren gel. The NP confirmed the resident's medications were not reviewed with a provider or reconciled upon readmission, and the DON confirmed the findings.
Delayed Reconciliation of Admission Antibiotic Order
Penalty
Summary
The facility failed to ensure continuity of care for a resident admitted from a general acute care hospital by not reconciling the admission orders to include vancomycin. The resident had diagnoses including COPD, dysphasia following cerebral infarction, and need for assistance with personal care. The MDS dated 3/2/2026 indicated the resident had no speech, was rarely or never able to express ideas and wants or understand others, had short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and was dependent on others for self-care and mobility. The resident was readmitted to the facility on 4/24/2026 at 6:12 PM. During interview and record review, the DON stated the physician’s order for vancomycin oral suspension 50 mg/ml, 2.5 ml via G-tube every 6 hours was entered on 4/25/2026 at 2:24 PM, and the pharmacy delivery receipt showed the medication was received at 6:38 PM that same day. The DON stated the first dose was given around 6 PM on 4/25/2026, and acknowledged there was no documentation explaining why the vancomycin order was not placed on admission. RN 1 stated the admitting nurse usually reconciles physician orders from the hospital, that first-dose antibiotics may be available through the ADC, but vancomycin oral suspension was not stocked there, and did not remember why the order was entered a day after admission.
Missing Admission Orders for Morphine and Foley Catheter Care
Penalty
Summary
Physician orders were not in place for the immediate care of 2 residents at the time of admission. For one resident with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, alcoholic polyneuropathy, heart failure, and COPD, the admission record and hospice care plan reflected comfort-focused care and multiple morphine orders entered on the order summary. However, the morphine order details listed several doses together and did not include specific pain level parameters for administration. An LVN stated the order was entered from a written hospice order and that pain level parameters were important so nurses would know what amount of morphine to give based on the resident's pain level. For the second resident, admitted with diagnoses including NSTEMI, sepsis, CKD, type 2 diabetes mellitus, and pneumonia, the baseline care plan documented that the resident used an indwelling catheter and included catheter-related monitoring and care interventions. The order summary on one date showed no orders for the catheter, while the next day the order summary reflected catheter care orders such as cleaning, irrigation, catheter change, securement, privacy bag placement, and keeping the collection bag below bladder level. During observation, the resident stated the catheter had been placed during prior hospital visits and that facility staff emptied the bag, checked the tubing, and cleaned it. The catheter bag was observed hanging below the bladder, off the floor, with a privacy bag. During interviews, an LVN verified there were no catheter orders in the chart at the time reviewed and stated the admitting nurse was responsible for entering orders and the team reviewed them. The ADON stated new admissions required the admitting nurse to input orders and call the doctor for clarifications, and that residents with a foley catheter had to have orders in place. The DON stated the resident should have had catheter orders since admission and verified the orders were not entered until later. The DON also stated it was important to have accurate orders so staff were aware of how to care for the resident and provide appropriate care.
Failure to Complete Admission Evaluations and Verify Diet Orders for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive admission and readmission evaluations and to ensure accurate, verified physician diet orders consistent with a resident’s swallowing needs. A resident with schizophrenia, bipolar disorder, and dysphagia was admitted with an admission evaluation and physician order indicating a mechanical soft diet with nectar thick liquids, despite hospital discharge documentation, nursing assessments, and progress notes lacking evidence to support the need for a mechanically altered diet. The facility did not document any contact with the transferring hospital or the resident’s prior group home to verify the resident’s previous diet consistency, swallowing history, or nutritional needs at the time of admission, contrary to facility policy and the 24-hour admission/readmission chart review checklist. Following a hospital transfer and readmission, the admission evaluation dated March 12, 2026, continued to list a mechanical soft diet with nectar thick liquids, while the physician’s order for that same date specified a mechanical soft diet with thin liquids. This inconsistency between the admission evaluation and the physician’s order was not verified, clarified, or supported by a documented assessment of the resident’s swallowing status. After another hospital transfer and readmission on March 16, 2026, the facility did not complete an admission evaluation as required by policy, and the prior physician order for mechanical soft texture with thin liquids remained active without documented review, clarification, or reassessment to ensure it reflected the resident’s current swallowing needs, prior diet consistency, or clinical condition. A Medical Nutrition and Hydration Evaluation completed by the Registered Dietitian on March 17, 2026, identified the resident’s current diet as mechanical soft with thin liquids but left blank the sections on therapeutic diet prior to admission and prior knowledge of mechanically altered diets, and did not document reconciliation of prior records, clinical history, or swallowing needs. An interdisciplinary care conference on March 18, 2026, attended by nursing, dietary, therapy, administration, and group home staff, documented the resident’s diet as puree with nectar thick liquids, and a subsequent Speech Therapy evaluation on March 20, 2026, recorded group home staff reports that the resident previously tolerated a puree diet with nectar thick liquids and identified oral dysphagia requiring Speech Therapy, with a recommendation for puree with nectar thick liquids. During interviews, the NHA and DON confirmed there was no documented admission evaluation for the March 16, 2026, readmission and no evidence that staff obtained or verified the resident’s diet status from the hospital or group home upon admission or readmissions to ensure accuracy of physician diet orders.
Failure to Transcribe Hospital Discharge Medication and Document Staple Removal Communication
Penalty
Summary
The facility failed to transcribe a hospital-ordered medication for a resident admitted with a displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, muscle weakness, and other lack of coordination. The hospital discharge paperwork included orders for staples to be removed and for Lovenox 30 mg twice daily for 21 days to prevent blood clots, but the facility's transcribed orders did not include the Lovenox medication in the resident's regimen. During interview, the resident stated the facility was okay but said the staples needed to be removed so discharge back to the community could occur. The Wound Care Coordinator reported the staples were not removed because the resident's primary care physician did not want facility staff to remove them and wanted the surgeon to remove them instead. The Wound Care Coordinator also stated the nurse who spoke with the physician did not document that conversation, and was unable to locate the Lovenox order, reporting that the admitting nurse was responsible for entering orders and that the IDT reviews hospital paperwork again to ensure everything is added, but was unsure how the medication was missed.
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