Failure to Assess, Communicate, and Report Change in Respiratory Status for Ventilator-Dependent Resident
Summary
A resident with a history of chronic respiratory failure, chronic kidney disease, congestive heart failure, and other comorbidities, who was ventilator-dependent, experienced a new onset of shortness of breath during the night shift. The respiratory therapist (RT) on duty documented the new symptom and increased the resident's oxygen flow from 5 to 8 liters per minute. However, there was no evidence of a comprehensive assessment to determine the cause of the shortness of breath, nor was there documentation of whether the intervention improved the resident's symptoms. The RT did not communicate this change in condition to the registered nurse on the same shift, to the staff on the following shift, or to the resident's physician for further consultation and treatment. The facility's policies required immediate notification of significant changes in a resident's condition to the physician and resident representative, as well as thorough documentation and assessment. Despite these requirements, no SBAR (Situation, Background, Assessment, Recommendation) was completed, and the change in the resident's respiratory status was not reported or followed up. Nursing staff did not perform or document any further assessments during the shift, and there was no indication that the resident was monitored for response to the increased oxygen or for further deterioration. The resident was later found deceased in the facility, with evidence suggesting they had been deceased for several hours before being discovered. Interviews with staff revealed discrepancies in the documentation and communication regarding the resident's condition and care. Several respiratory therapists and nursing staff confirmed that an increase in oxygen flow should be considered a change in condition requiring assessment and communication. The lack of follow-up assessment, failure to notify the physician, and inadequate communication among staff contributed to the deficient practice, which resulted in a finding of immediate jeopardy.
Removal Plan
- The Director of Nurses along with a consulting respiratory therapist will provide education to all nurses and RT's who will be delegated to the respiratory unit related to recognition of all respiratory changes of condition to include policies and procedures related to same and or other physiological changes of condition.
- Education included staffing expectations for all shifts related to the respiratory unit, change of condition policy and procedures titled: Physician Notification, respiratory policy and procedures including Mechanical Ventilation: Set up and Monitoring, Oxygen Administration, Pulse Oximetry, Tracheostomy Care, notification and documentation expectations with change of condition, where to look for a comprehensive list of orders and treatment within the EHR, shift to shift report expectations and use of 24 hour report board.
- Competency exercises will include a return demonstration on care for a resident with a ventilator and or other open airway that includes verbal affirmation of what, when and whom to report any changes in condition.
- Nursing and respiratory staff will collaborate and communicate any change in condition as a team, implementing appropriate interventions as ordered by provider.
- Signs were posted at the clinical hub on the vent unit to inform clinical staff that if they have not received the competency, they are not permitted to work on the unit until they've received the training.
- All nurses and RT's will be required to view the in-service prior to their next working shift. Once present for their scheduled shift a competency will be provided by a DON or a verified competent facility designee.
- A competent RN will be designated to respond to all emergency situations for ventilator and tracheostomy residents at all times. The RN will be delegated and present and available to ensure timely and comprehensive assessments to any resident demonstrating a potential change in condition.
- The unit will be staffed with an RN who has demonstrated competency in caring for ventilator residents.
- CNAs will be scheduled to meet residents, and RT's scheduled as necessary.
- The Change of Condition policy, Physician Notification has been reviewed and modified to include: Examples of Change of Condition, notification expectations with change of condition, documentation of a change of condition, vital sign expectations.
- All changes in condition will be listed on the 24-hour report board.
- Facility standard of practice policies from [NAME] have all been reviewed, and implemented to include: Mechanical Ventilation: Set up and Monitoring, Oxygen Administration, Pulse Oximetry, Tracheostomy Care.
- Shift to shift report expectations protocol has been developed to use with 24 hour report board.
- Medical Director-EE consulted during the development of this corrective action plan.
- The DON and or designee will review progress notes and 24-hour report board for any changes of condition to ensure all condition changes have been recognized and appropriate for the residents status. An audit tool has been developed to support identification of any condition change. Audits will be conducted with ad hoc training provided as necessary for any missed opportunities.
- The DON and or designee will observe the delivery of respiratory care assigned by nurse or RT.
- All audits will be brought to the Quality Improvement Committee for review and recommendations.
Penalty
Resources
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The deficiency involves two residents for whom the facility did not follow established care expectations. A resident with multiple risk factors for impaired skin integrity reported a blister on the back of the thigh that later tore during a mechanical lift transfer; despite the resident’s report and a staff-taken photo days earlier, the skin alteration was not formally identified or assessed until it was observed by surveyors, revealing a MASD area on the posterior thigh. In a separate case, a resident receiving prn Oxycodone and care-planned as at risk for constipation went multiple times more than three days without a documented BM, including one eight-day interval, with no documented nursing interventions, no laxatives given, and no evidence of physician notification, even as prn opioid doses continued.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with a history of hip fracture, muscle weakness, COPD, osteoporosis, and moderate cognitive impairment experienced an unwitnessed fall and was found on the floor next to an unlocked wheelchair, reporting elbow pain with bruising and swelling. Later the same day, an Interact evaluation documented pain and marked bruising and swelling in the right elbow, trochanter, and thigh, and the physician ordered immediate X‑rays of the right elbow, femur, and hip. Due to inclement weather, the X‑ray company did not come, and despite the resident’s ongoing pain and the documented injuries, the resident was not sent to the ER for imaging that day. X‑rays obtained the following morning showed acute fractures of the right hip and right elbow, and subsequent hospital evaluation identified additional pelvic and humeral fractures, confirming that there was a significant delay between the fall and the identification of these injuries.
A resident with vascular dementia, kidney disorders, a history of UTIs, and frequent incontinence returned from the hospital with an acute UTI diagnosis and instructions to start cephalexin 500 mg PO four times daily for seven days after receiving Rocephin. Facility documentation showed no evidence that the AVS was reviewed or obtained from the hospital or the resident’s POA, and there was no record of the resident refusing care or refusing to provide the AVS. A physician order for cephalexin was not entered until two days after readmission, and the MAR showed the antibiotic was not started until that time. An RN reported being unaware of the UTI or need for antibiotics, while the DON acknowledged the lack of documentation and attempts to obtain the AVS, and the resident denied refusing to share the AVS.
A resident with adult failure to thrive, COPD, and protein calorie malnutrition had a physician order for weights three times weekly at a specific time, but staff did not obtain or document these weights on multiple ordered days, and there was no documentation of refusals. The DON confirmed the missing weights and lack of refusal documentation. Facility policy required that ordered and additional weights be obtained as indicated by diagnoses or providers and recorded in the EMR, but this was not followed for the identified dates.
Surveyors found that the facility failed to provide ordered and coordinated care in several cases. A hospice resident with severe cognitive impairment was lowered to the floor during a nighttime episode, after which staff documented no suspected injury and did not notify hospice, despite the resident later reporting high pain scores, visible bruising, and difficulty bearing weight; imaging was delayed and ultimately revealed a left femoral neck fracture requiring surgery. Another resident with severe cognitive impairment and cardiovascular disease had antihypertensive medications repeatedly held per BP parameters without provider notification, and on one occasion the medications were given despite BP below the ordered threshold. A third resident with dementia and a diabetic foot wound had daily wound care documented as completed, but observation showed a dressing dated two days earlier, indicating the treatment was not performed as ordered. Additionally, two residents with dementia and mobility limitations had physician orders or care plan interventions for perimeter mattresses that were not timely implemented, with one mattress topper left in a bag in the room and another order delayed, and staff, including the DON and an LPN, were unaware of the status of these safety devices.
Failure to Address New Skin Breakdown and Constipation in Residents at Risk
Penalty
Summary
The deficiency involves the facility’s failure to identify and treat a new skin condition for a resident at high risk for impaired skin integrity. The resident had diagnoses including spinal stenosis, radiculopathy, type II diabetes, hypertension, a current surgical wound, a history of MASD, anemia, and morbid obesity, and a care plan requiring weekly head-to-toe skin assessments and prompt reporting of abnormal findings. A weekly skin assessment documented on 03/30/25 indicated no skin issues. However, the resident later reported having what she believed to be a blister on the back of her left thigh that tore during a mechanical lift transfer, resulting in a wound that she stated was not addressed by staff despite her request for a nurse assessment. A nurse recalled the resident mentioning a blister weeks earlier but reported not seeing any area at that time. On 04/08/26, observation revealed an area on the back of the resident’s left thigh that appeared dry, peeling, and healing, approximately two by three inches, which an LPN confirmed. Subsequent documentation that same day described a new MASD area on the left posterior thigh measuring eight by 12 centimeters. The resident reported that a CNA had taken a picture of the back of her thigh on 04/03/26 using the resident’s phone, showing the area existed several days before the facility formally identified and documented it. A supervising RN confirmed that if a wound had been found and photographed on 04/03/26, it should have been identified and treated before 04/08/26, when the facility became aware of the skin alteration through the surveyor. This sequence shows a gap between the resident’s report of a skin issue, staff awareness via a photograph, and the formal recognition and assessment of the skin impairment. A second deficiency concerns the facility’s failure to implement interventions when a resident went more than three days without a bowel movement despite being at risk for constipation related to opioid use. The resident had diagnoses including adult-onset diabetes mellitus, generalized osteoarthritis, hypokalemia, depression, and anxiety disorder, and had an order for prn Oxycodone 5 mg by mouth every four hours for pain since admission. Her care plan identified her as at risk for constipation due to opioid use, with a goal of having a bowel movement at least every three days and interventions to observe for signs and symptoms of constipation. Bowel records over a 30-day period showed three episodes where no bowel movement was documented for more than three days: one four-day interval, one eight-day interval, and another four-day interval. During these periods, there was no documentation of any nursing interventions to promote a bowel movement, no laxatives administered, and no evidence of physician contact for constipation management, even though the resident continued to receive prn Oxycodone. The DON acknowledged the extended intervals without recorded bowel movements and the lack of documented interventions, and stated there was no bowel protocol in place, although it was an expectation that nurses contact the physician if no bowel movement occurred within three to four days.
Plan Of Correction
Formatted text (without <text> tags or quotes): 1. Resident #8 had their skin alteration evaluated by the wound nurse and appropriate treatment orders implemented on 4/8/26. Resident #99 had a medium bowel movement documented on 4/17/26 by the STNA and was assessed by the RN Unit Manager on 5/7/26 with no ill effects of going greater than 3 days without a bowel movement. Licensed Nurse obtained physician's order on 5/7/26 for stool softener. 2. Like Residents are identified as residents who have a skin alteration. A full-house skin sweep was completed by the Wound Nurse on 4/23/26 to identify any unreported skin alterations. Utilizing the Skin Alteration Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that skin alterations are evaluated and have appropriate treatment orders in place. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who have greater than 3 days with no bowel movement documented as indicated on the clinical alerts via PCC. Utilizing the Change in Condition Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that residents who do not have a bowel movement documented within three days have documentation in place for appropriate intervention/follow up. This audit will look back to 5/2/26. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNAs, including CNA #373 and RN #330 on the Skin Management and Notification of Change Policy to include reporting of skin alterations and notifying the physician of a resident change in status. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses utilize PCC to identify and address clinical alerts related to no bowel movements greater than three days and to follow the Notification of Change Policy regarding physician notification. This education will be completed on or before 5/13/26. 4. Utilizing the Skin Alteration Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that skin alterations are evaluated and have appropriate treatment orders in place. Noncompliance noted during the audits will be corrected with appropriate treatment orders in place. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Change in Condition Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that residents who do not have a bowel movement documented within three days have documentation in place for appropriate intervention/follow up. Noncompliance noted during the audits will be corrected with documentation in place for appropriate intervention/follow up. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Delay in Diagnostic Evaluation and Treatment After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and services following a resident’s unwitnessed fall. The resident had been admitted with a nondisplaced intertrochanteric fracture of the right femur, muscle weakness, COPD, osteoporosis, and avascular necrosis, and had moderate cognitive impairment. On the date of the incident, staff heard the resident yelling and found her sitting on the floor, leaning on the wheel of an unlocked wheelchair beside the bed. She reported right elbow pain, and staff noted bruising, swelling, and normal range of motion. She was assisted back to bed. An Interact Change in Condition Evaluation later that evening documented marked localized bruising, swelling, or pain not only in the right elbow but also in the right trochanter and right thigh, and indicated the resident had pain. Following the fall, the resident complained of right hip and upper leg pain and requested that staff call her brother. The physician was notified and immediate X‑rays of the right elbow, right femur, and right hip were ordered. However, the X‑rays were not obtained that day because the contracted X‑ray company could not come to the facility due to inclement weather. The DON confirmed that, despite the inability of the X‑ray company to respond, the resident was not sent to the ER that day to obtain imaging as an emergency measure. The Medical Director acknowledged awareness that the X‑rays were delayed until the following day and attributed the delay to the X‑ray company’s availability. The X‑rays were finally completed the next morning and revealed an acute intertrochanteric fracture of the proximal right femur and an acute comminuted fracture of the olecranon process of the proximal ulna, with associated osteopenia, joint effusion, and soft tissue swelling. Subsequent hospital evaluation identified additional fractures involving the right superior and inferior pubic rami and redemonstration of an impacted proximal humeral fracture with evidence of healing. The resident’s brother confirmed that nearly 24 hours elapsed between the fall and the discovery of the fractures, and he expressed concern about the delay in treatment. The facility’s Managing Falls and Fall Risk policy stated that staff would try to minimize complications from falling, but in this case, the resident did not receive timely diagnostic evaluation and related care after the fall when the ordered X‑rays could not be obtained as planned.
Failure to Implement Hospital Discharge Orders for UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure continuity of care and timely implementation of hospital discharge orders for a resident treated for an acute urinary tract infection (UTI). The resident, who had vascular dementia, kidney and ureter disorders, a kidney cyst, a history of UTIs, and frequent urinary and bowel incontinence, was moderately cognitively impaired and required substantial assistance with toileting. A hospital after visit summary (AVS) documented diagnoses of kidney stone, kidney cyst, and acute UTI, with instructions to initiate cephalexin 500 mg by mouth four times daily for seven days following a dose of Rocephin. The hospital record also noted a left renal calculus with partial obstruction and abnormal urinalysis findings. Upon the resident’s return to the facility, a progress note recorded the readmission, but from that date until three days later there was no documentation of refusal of care or refusal to provide the AVS. The physician order for cephalexin 500 mg four times daily for seven days was not created until two days after the resident’s readmission, and the medication administration record showed the antibiotic was not started until that later date, with the first dose given upon rising. A registered nurse interviewed denied knowledge of the resident’s UTI or the need for antibiotic therapy upon readmission. The DON stated that the resident had refused to provide the AVS, but confirmed there was no documentation of such refusal and no evidence that staff attempted to obtain the AVS from the hospital or contact the resident’s power of attorney, who had been present at the time of hospital admission. The DON also confirmed that the resident returned with a diagnosis of acute UTI and an order to start cephalexin four times daily, which was not initiated until days later, and was unsure if the antibiotic was available in the emergency box. In contrast, the resident reported being welcoming and denied refusing to give staff the hospital AVS.
Failure to Obtain and Document Physician-Ordered Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights for a resident in accordance with physician orders and facility policy. The resident was admitted with diagnoses including adult failure to thrive, COPD, and protein calorie malnutrition, and had a physician order dated 02/02/26 to be weighed every Monday, Wednesday, and Friday at 6:00 A.M. due to COPD. The resident’s MDS assessment indicated severely impaired cognition. Review of the weight records for February and March 2026 showed multiple missing weight entries on ordered days, with no documentation that the resident refused to be weighed on those dates. During an interview, the DON confirmed that the resident had an active order for thrice-weekly weights at 6:00 A.M. and acknowledged that there were no documented weights or refusals for the specified dates in February and March 2026. Review of the facility’s undated Weights Policy and Procedure showed that staff were to weigh all residents upon admission, weekly for four weeks, and then monthly unless specific diagnoses indicated a need for more frequent weights, and that additional weights could be ordered by the physician, dietitian, or nursing staff. The policy also required that all resident weights be recorded in the weight/vital section of the electronic medical record, which did not occur for the identified dates for this resident.
Plan Of Correction
DON performed a head-to-toe physical assessed Resident #12 on 03/26/26. There were no negative effects related to the residents' missing weight documentation that were identified during the Annual Survey. LNHA notified Primary care provider of missing weight documentation on 03/26/26. Primary care provider gave new orders to change weight frequency to weekly. On or before 4/30/26, DON/Designee will review residents' weight orders and ensure weights are scheduled in Point Click Care, per physician's orders. On or before 4/30/2026, licensed and unlicensed nursing staff will be educated on: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Also, on or before 04/30/026, licensed and unlicensed nursing staff will be educated on: the importance and procedure of following weight order/care plan and ensuring proper documentation. DON/Designee will perform audits x5 medical records weekly x4 weeks; then as determined by QAA. This audit will list a resident identifier (facility identifier), current weight order, and if the weight(s) were obtained per current physician's orders. Negative findings identified during the audits will be investigated / verified. PCP alerted for reporting/review/intervention, and responsible party alerted of any negative findings and/or new orders or concerns.
Failure to Follow Orders, Monitor Changes in Condition, and Implement Safety Devices
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and goals, as well as failures in comprehensive monitoring after a change in condition. One hospice resident with severe cognitive impairment was lowered to the floor from bed during an early morning episode in which she believed her bed was on fire. Staff documented no pain, no change in range of motion, and no suspected injury immediately after the incident, and planned only to monitor for pain and bruising. Hospice was not notified of the incident at that time. Over the next several days, documentation showed increasing complaints of left hip and leg pain with pain scores up to eight and nine out of ten, bruising to the left buttock and knee, and repeated administration of PRN acetaminophen, which staff recorded as effective. The NP noted soreness and bruising, low suspicion of fracture, and initially ordered but then cancelled x‑rays after discussion with staff, based on the belief the resident had been lowered rather than fallen and had no uncontrolled pain. Hospice staff later assessed the resident, observed significant pain and favoring of the left leg, and requested imaging; x‑rays eventually revealed a probable subcapital fracture of the left femur, and subsequent hospital evaluation confirmed an acute impacted intracapsular subcapital femoral neck fracture requiring surgical fixation. The resident’s son and hospice nurse reported that the resident had complained of pain since the incident, that the facility delayed notifying the son of the event, and that hospice had to reiterate the need for imaging. Another deficiency involved a resident with severe cognitive impairment and multiple cardiovascular diagnoses who had physician orders for three antihypertensive medications (Amlodipine, Hydrochlorothiazide, and Lisinopril) to be held if systolic blood pressure was less than 120. The MAR showed numerous blood pressure readings below the ordered threshold throughout the month, resulting in the medications being held on multiple occasions, including three consecutive days. There was no documentation that the physician or NP was notified of these repeated medication holds. Additionally, on one date when the systolic blood pressure remained below 120, all three medications were administered instead of being held, contrary to the physician’s parameters. The DON confirmed that the provider had not been notified of the repeated holds and that the medications should have been held on the date they were administered. A further deficiency concerned a resident with diabetes, dementia, and a left dorsal foot wound who had a physician order for daily wound care with normal saline, Medihoney, calcium alginate, and appropriate dressings. The TAR for the month showed the treatment as completed daily; however, during observed wound care, the kerlex dressing on the resident’s foot was dated two days prior, indicating the dressing had not been changed as ordered. The LPN performing the dressing change confirmed the date and believed the dressing was to be done daily and as needed, revealing a discrepancy between documentation and actual practice. Additional deficiencies involved failure to implement ordered perimeter mattresses for residents at risk for falls or needing defined bed boundaries. One resident with dementia, muscle weakness, and dependence for transfers had a physician order in place for an air perimeter mattress for several months. Observations showed a bag containing a perimeter mattress topper sitting on the resident’s chair rather than on the bed, and staff, including the LPN and DON, were initially unaware of what was in the bag or that it needed to be applied. The DON later confirmed that the perimeter mattress order had been in place since January and that the topper should have been on the bed. Another resident with dementia and cognitive deficits had a care plan intervention for a bari‑bed with perimeter mattress and a later physician order for a perimeter mattress to assist with bed boundaries. The DON stated she was unsure when this resident actually received the mattress and that the physician order was not entered until weeks after the care plan intervention was documented, indicating a delay in implementing the ordered safety device.
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