Failure to Review and Document Resident Care Leads to Medication Errors
Summary
The facility failed to ensure that the physician reviewed the residents' total program of care, including treatments, at each visit, leading to inappropriate medication orders and administration for two residents. Resident #2, who was admitted with orders for nothing by mouth (NPO) and a feeding tube, did not have an NPO order included in the admission orders. Despite recommendations from a speech therapist, the resident was prescribed and administered oral medications such as Tylenol and Tamiflu, which contradicted the NPO status. Attempts to contact the responsible Physician Assistant were unsuccessful. Resident #5 was also admitted with orders for nothing by mouth and a feeding tube. However, the resident was evaluated by a Physician Assistant who ordered oral medications, including Amoxicillin, Prednisone, and Tamiflu, which were administered despite the NPO status. Additionally, a pharmacy review recommended discontinuing Proscar and starting Rapaflo, but the Nurse Practitioner failed to discontinue Proscar, resulting in the resident receiving both medications for 30 days. The facility's Physician's Visit policy requires the attending physician to review the resident's total program of care and document appropriately at each visit. However, this was not adhered to, as evidenced by the inappropriate medication orders and administration for Residents #2 and #5. The Medical Director acknowledged the oversight and emphasized the need for physician orders to reflect the residents' intake status, particularly for those deemed NPO.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, schizoaffective disorder, liver cirrhosis, and a severely impaired BIMS score was temporarily moved to a secured unit for closer monitoring after an episode of shortness of breath without a written, signed, and dated physician order, despite facility policy requiring such an order for secured unit placement. Nursing staff reported that the DON directed the transfer to and from the secured unit and confirmed no physician order was obtained, while also expressing uncertainty about order requirements for a Wander Guard. Record review corroborated the absence of an order for the secured unit placement, and the facility’s wandering and elopement policy lacked specific criteria for Wander Guard implementation.
A resident with pancreatic cancer and cirrhosis, including ascites and esophageal varices, had labs ordered that showed a significantly elevated ammonia level. The PA reviewed the abnormal result, documented "no new orders," and did not enter any treatment, monitoring parameters, or the intended order to recheck the ammonia level, nor a progress note explaining the assessment. Days later, the resident developed altered mental status and abdominal pain, and was sent to the ED at the family’s insistence, where an even higher ammonia level was found and hepatic encephalopathy was diagnosed, requiring treatment with lactulose and a multi-day hospitalization.
Surveyors found that multiple residents’ physician orders were not reviewed and signed by the admitting physician at admission and monthly as required by facility practice. Record review showed that several newly admitted residents lacked timely physician signatures on their orders on expected review dates. The DON reported that the admitting physician is responsible for signing admission orders within 48–72 hours and then monthly, but was unaware that this was not occurring consistently. The Medical Director confirmed the expectation for timely signatures and noted that the electronic clinical record does not prompt physicians to sign orders, which may have led to missed signatures, and the facility could not provide a written policy specifying the frequency of physician order review.
A resident with multiple neuropsychiatric diagnoses became less responsive, prompting a nurse to contact a PA who ordered STAT labs and later ordered D5% 0.45% NS IV fluids. The lab results showed a critically high blood glucose of 732, but the PA did not document reviewing these labs and still ordered continuous IV fluids containing dextrose, which nursing staff implemented and clarified over the next day. The resident remained on D5% 0.45% NS while serial nursing notes documented ongoing infusion, progressive lethargy, and repeated glucometer readings of "Hi," leading to insulin administration per NP orders and eventual EMS transfer to the hospital for high blood sugar and altered mental status. In interview, the PA stated they were unaware of the critical glucose level before ordering the dextrose-containing IV fluids, and the DON acknowledged the order could have been questioned by nursing staff, contrary to facility policy requiring provider review and analysis of abnormal labs.
A resident with CHF and chronic pulmonary edema was readmitted with a hospital report and a physician telephone order indicating a 750 ml/day fluid restriction, but the order was not properly documented or incorporated into the active physician orders. The RN who received the hospital report acknowledged missing the entry of the fluid restriction, and the telephone order form lacked the signature and title of the person who transcribed it, making it impossible to identify who took the order or confirm that the person was licensed. The ADON and Medical Records Director were unable to locate the signed copy of the telephone order or any history of the fluid restriction in current or discontinued physician orders, contrary to facility P&P requiring licensed staff to document telephone orders with signature and title and for the physician to countersign them.
A resident’s medical record contained psychiatric NP evaluations and consultations that were completed but not uploaded in a timely manner, with delays of up to a month between completion and upload. During a complaint survey, surveyors found that several psychiatric visit notes following an incident were missing from the record on the day of review, despite the visits having already occurred. Interviews with the NHA and DON revealed that the facility uploads NP documentation promptly upon receipt, but there is a delay in the process by which the NP’s notes are transmitted to the facility. This delay affected both general progress notes and notes with medication changes, including an example of a Trazodone dose increase documented several days before the note was uploaded, resulting in physician/NP notes not being readily available in the medical record after resident visits.
Failure to Obtain Physician Order for Temporary Secured Unit Placement
Penalty
Summary
The deficiency involves the facility’s failure to obtain a written, signed, and dated physician order for a resident’s placement in a secured unit, as required by facility policy. Record review showed that a female resident with diagnoses including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension, and a severely impaired BIMS score of 4, had no physician order dated 03/11/26 for placement in the secured unit on her Order Summary Report. The resident’s admission record reflected an original admission date of 12/06/22 and a readmission date of 08/01/25. The facility’s Secured Unit Admission Criteria, dated 3/2026, specified that a physician order for placement would be obtained for secured unit placement. Interviews confirmed that the resident was moved to the secured unit without a physician order. LVN B, the usual nurse for the secured unit, stated the resident was placed there the prior week for closer monitoring after an episode of shortness of breath and that the DON handled the placement; LVN B was unsure whether an order was required for a Wander Guard. LVN D reported that the resident was in her regular room on one day and in the secured unit the next morning, and that she was told in report the resident had shortness of breath overnight and was placed in the unit for closer observation, then later directed by the DON to return the resident to her room. The DON stated the resident was placed in the secured unit around 11:00 p.m. and returned to her room the following morning, acknowledged there was no physician order for the placement despite policy requiring one, and stated she did not know why she had not obtained the order. Review of the facility’s Wandering and Elopements Policy showed no criteria or implementation guidance for the use of a Wander Guard.
Failure to Act on Elevated Ammonia Level Resulting in Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident’s abnormal laboratory result was appropriately evaluated and addressed by the practitioner. The resident had diagnoses including pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A progress note indicated that a cancer center appointment was cancelled and that the NP’s order for labs, including an ammonia level, should be followed. The resident’s ammonia level, drawn the following day, was 76 (reference range 9–35) and marked as high. The result was circled, annotated “NNO” (no new orders), and noted to have no previous ammonia level for comparison, and was signed by PA #1. There were no new treatment orders, no monitoring orders, and no corresponding progress note documenting assessment or clinical reasoning in the medical record related to this abnormal result. Subsequently, the resident experienced a change in mental status and abdominal pain. A progress note documented that the resident was sent to the ED for further evaluation after the resident’s family insisted on transfer. In the ED, the resident was found to have an ammonia level of 180 (reference range 9–35) and was diagnosed with hepatic encephalopathy. The resident was treated with lactulose and remained hospitalized for six days before discharge. The attending physician/Medical Director later stated that the resident had an elevated ammonia level that PA #1 had missed and acknowledged that the family was not happy with the situation. During interview, PA #1 confirmed that she had reviewed the elevated ammonia level and had not written any orders. She stated that because the resident did not have a history of hepatic encephalopathy and nursing staff had not reported a change in mental status, she decided not to treat the resident and did not write monitoring orders, believing such monitoring to be part of routine nursing care. She also reported that she had intended to recheck the ammonia level in a couple of days but failed to enter the order into the medical record. This failure to order treatment or monitoring, and the omission of the planned repeat ammonia level, occurred despite the clearly abnormal lab value and contributed to the resident’s subsequent hospitalization for hepatic encephalopathy.
Failure to Ensure Timely Physician Review and Signature of Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for ensuring that physicians review, sign, and date resident orders at admission and on a monthly basis. For five of twelve sampled residents, clinical record review showed that physician orders were not reviewed and signed in accordance with facility practices. One resident admitted on 1/11/26 did not have orders reviewed and signed on 1/14/26 or 2/1/26, another admitted on 1/17/26 lacked signed orders on 1/20/26 and 2/1/26, and a third admitted on 1/18/26 had no evidence of order review and signature on 1/21/26 or 2/1/26. Two additional residents admitted on 2/3/26 and 2/15/26, respectively, did not have their orders reviewed and signed on 2/6/26 and 2/18/26 as expected. During interviews, the DON stated that the admitting physician is responsible for reviewing and signing admission orders when completing the initial history and physical within 48–72 hours of admission and then monthly, and reported being unaware that orders were not consistently signed. The Medical Director similarly stated that the admitting physician is responsible for signing admission orders within 72 hours and monthly thereafter, and explained that when the clinical record is accessed there is no prompt to sign orders, which may have contributed to orders being missed. When requested, the facility was unable to provide a policy specifying the required frequency for physician order review.
Failure to Review Critical Glucose Result Before Ordering Dextrose-Containing IV Fluids
Penalty
Summary
The deficiency involves the failure of the attending provider to review and act upon critical laboratory results before ordering and continuing IV fluids containing dextrose. A resident with psychotic disorder with delusions, delirium, Alzheimer's disease, stroke, and mood disorder was noted by a CNA as "wasn't herself" on the morning of 12/8/25. Nurse B contacted the on-call PA, who ordered STAT labs including a CBC and CMP. Labs drawn that morning and reported at 12:37 PM showed a critically high blood glucose level of 732 (normal 70–99). Nurse B later documented at 3:24 PM that they reviewed the lab results with the PA while the PA was in the building, and that new orders were received for D5% 0.45% NS at 125 ml/hr for 3 liters, with an IV started but then pulled out by the resident. The PA’s progress note for 12/8/25 documented an assessment of acute kidney injury and a plan to give 2 liters of IV fluid continuous, but did not document review of the STAT labs or specify the type of IV fluid. Subsequent nursing notes show that on the afternoon of 12/8/25 the PA called back with new orders for hypodermoclysis, which was initiated. On 12/9/25, Nurse G documented placement of a new PIV and that the resident was hooked up to IV fluids as ordered, specifically D5% 0.45% NS per the PA’s prior order. Nurse H documented an order clarification for D5% 0.45% NS infusing at 125 cc/hr times 2 liters, and Nurse I documented that the resident had a peripheral IV in the right forearm with D5% 0.45% NS infusing at 125 cc, bag 2 of 2. In the early hours of 12/10/25, Nurse C documented that the resident was resting in bed with D5% 0.45% NS infusing via right arm PIV, and that the resident was hard to arouse. A blood sugar check at that time read "Hi" on the glucometer, and the on-call NP was contacted. New orders were received to give 12 units of Lispro insulin, recheck in 2 hours, and repeat 12 units if the blood sugar still read "Hi," with instructions to call back if it remained "Hi" after the second dose. Subsequent notes by Nurse C documented repeated "Hi" blood sugar readings, administration of Lispro insulin, the resident being lethargic and difficult to arouse, and that an ambulance was called for transfer to the hospital. Hospital records indicated the chief complaint was high blood sugar and altered mental status, and EMS reported the patient was receiving D5 fluid hydration on their arrival. In an interview, the PA stated they were not aware of the glucose level of 732 prior to ordering D5% 0.45% NS, acknowledged they did not document lab review, and stated they would not have ordered IV fluid with dextrose if they had known. The DON indicated that the PA’s order for D5% 0.45% NS could have been questioned by the nurse who received the critical glucose result and implemented the order. The facility’s policy requires providers to review laboratory tests during visits and analyze abnormal results with documented rationale and interventions.
Failure to Properly Document and Countersign Physician Telephone Order for Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician telephone order for a fluid restriction was properly documented, signed, and incorporated into the resident’s active physician orders. A resident with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension was originally admitted and later readmitted with a hospital report indicating a fluid restriction of 750 ml per day. The resident’s MDS showed intact cognition and dependence on staff for ADLs. On readmission, the RN Hospital to RN Facility admission report documented the 750 ml/day fluid restriction, and a Physician’s Telephone Order form dated the same day also indicated a fluid restriction of 750 ml/day due to chronic pulmonary edema. However, the fluid restriction was not entered into the physician’s orders or reflected in the physician order recap covering the admission period. During interviews and record reviews, RN 1 stated he became aware of the fluid restriction from the hospital report but missed inputting the restriction into the physician’s orders. When reviewing the Physician’s Telephone Orders, RN 1 stated he did not transcribe the order and could not identify who did because there was no name or signature on the form. The ADON similarly could not determine who transcribed the telephone order, whether that person was a licensed nurse, or whether the order had been entered into the charting system, and confirmed the fluid restriction was not present in the physician order summary. The Medical Records Director reported that the white copy of the Physician’s Telephone Orders, which should have been returned within five days after the physician’s signature, could not be located, and there was no history of the fluid restriction order in the current or discontinued physician orders. The facility’s P&P required that telephone orders be received only by licensed personnel, reduced to writing with date, time, signature and title of the person transcribing, and countersigned by the physician at the next visit or electronically, which was not followed in this case.
Delayed Upload of Psychiatric NP Notes to Medical Record
Penalty
Summary
Surveyors identified a deficiency related to the timeliness of physician and NP documentation being available in the medical record following resident visits. For one resident reviewed during a complaint survey, the medical record showed multiple psychiatric evaluations and consultations by a psychiatric NP, but the completion dates of these assessments did not match the dates they were uploaded into the resident’s electronic record. In some instances, there was up to a month delay between the date the NP completed the evaluation and the date the note was uploaded into the miscellaneous section of the record. During review on one survey date, several psychiatric visit notes following an incident were not yet present in the resident’s record, despite the visits having already occurred. Further review and interviews with the NHA and DON confirmed that the process for handling the psychiatric NP’s documentation involved a delay between completion of the notes and their receipt and upload by facility staff. The DON reported that the staff member responsible for medical records uploads the NP’s documents as soon as they are received, indicating that the lag occurs before the notes reach the facility. Surveyors noted that this delay affected not only general progress notes but also notes containing medication changes, including an example where a note documenting an increase in Trazodone was completed on one date and not uploaded until several days later. The deficiency centered on the lack of timely availability of physician/NP notes in the resident’s medical record after visits and assessments had been completed.
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