Failure to Provide Timely Medical Assessment and Intervention
Summary
The facility failed to ensure that a resident received care and services consistent with professional standards of practice, as outlined in the Wisconsin Nurse Practice Act. A resident experienced a significant change in condition, including weakness, abnormal lung sounds, a fever, cough, and shortness of breath. Despite these symptoms, the facility did not complete a comprehensive nursing assessment by a registered nurse, nor did they consult with a physician as the resident's condition continued to deteriorate. The resident, who was admitted with diagnoses including end-stage renal disease, congestive heart failure, and a left ankle fracture, showed signs of respiratory distress and cognitive decline. The last documented RN assessment occurred in the morning, and it was not until 12.5 hours later that a physician was consulted, which included interventions. Throughout the day, the resident's condition worsened, and the facility's failure to act promptly and appropriately resulted in the resident's death later that night. Interviews with staff revealed that there was a lack of communication and follow-up regarding the resident's deteriorating condition. The LPN on duty did not speak to a physician or have an RN assess the resident before their passing. Additionally, the facility's policy for notifying physicians and conducting assessments was not followed, contributing to the immediate jeopardy situation.
Removal Plan
- The Administrator, Chief Nursing Officer of the Hospital, and Facility Medical Director outlined the steps to contact a physician 24 hours a day, 7 days a week. A physician will be available to assess patients 24 hours a day. This process has been communicated to all Hospitalists, Hospital Nurse Practitioners, Hospital RN House Supervisors, Administrator, Administrator Assistant, Director of Nursing, Assistant Director of Nursing, and the President of Hospital Operations.
- All Nursing staff were contacted and educated to ensure an RN assessment is completed when a resident presents with a change of condition, deterioration in their condition, and/or an immediate MD/NP consultation is needed in order to alter treatment if necessary.
- The Hospital Chief Nursing Officer reeducated every RN Hospital House Supervisors to implement the following: Frequent rounding is required in the facility to check on staff and ensure patient safety. If anyone from the facility calls the Nursing Services Office and has questions, are worried about patient safety, or seems that they are unsure what to do they are to immediately go to the facility and assess the situation and assist with calling physicians as needed. When RN House Supervisors are here, they are in charge of the hospital and everyone in it including patients and staff.
- The Hospitalist Physician assigned to the orange phone will respond to all calls and the Hospitalist Physician assigned to the black phone will respond to all calls.
- The facility Protocol for Condition Changes was revised to include the following; If a significant change in the resident's physical or mental condition occurs, a head-to-toe assessment of the resident's condition will be conducted by the RN on duty or by the MD/NP on call. The Director of Nursing has educated all Nursing Staff to the revision.
- A SNF Change of Condition Notification Protocol was developed to outline the new process of notifying the Physician of any change in a patient's condition.
- The RN Hospital Shift Supervisors will provide frequent rounding at the facility on all shifts and check in with RN/LPN on shift.
- RN Hospital Shift Supervisors will provide assistance with any patient at the facility and will come to the unit if the facility Nursing needs immediate assistance.
- If an LPN is on duty when the DON and/or ADON are not on duty, the RN Hospital Shift Supervisor will be contacted to conduct and document an RN assessment of the patient if there has been a change of condition or if the patient needs immediate assistance.
- If the facility nurse is unable to reach a physician using the protocol below; the nurse will contact the RN Hospital Shift Supervisor.
- If the nurse is unable to reach a physician using the call tree outlined in this protocol, the nurse is to contact the RN Hospital Shift Supervisor back who will then contact the Hospital Chief Nursing Officer for support.
- RRTs and Code Blues called within the facility will follow the RRT or Code Blue protocols located in the Emergency Management Binder.
- A SNF Change of Condition Reporting Protocol was revised to include the following: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status.
- The Director of Nursing will audit all charts for any Change of Condition to ensure an RN, or MD/NP Assessment was completed.
- The Quality Assurance Performance Improvement Committee will review these audits to ensure compliance.
- If an occurrence with a change of condition is identified during audits, the Director of Nursing will meet with the Nurses to identify the Root Cause of the occurrence and put appropriate measures in place for that specific occurrence to ensure compliance.
- The Quality Assurance Performance Improvement Committee will meet to discuss the event and corrective measures to ensure compliance.
- The Facility Assessment has been updated to include RN Hospital Supervisors as a facility resource. The Facility Assessment has also been updated to reflect the training topic of Identification of patient/resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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