Delayed Transfer to Higher Level of Care Following Change in Condition
Summary
A resident with a history of atrial fibrillation and a recent femoral neck fracture was admitted to the facility and prescribed apixaban. The resident was cognitively intact at baseline but required assistance with activities of daily living. On the evening in question, the resident exhibited a sudden change in condition, including restlessness, lethargy, increased confusion, and an elevated, irregular pulse rate of 156 BPM, which was a significant deviation from previous stable vital signs. The LPN on duty recognized the resident's altered mental status and abnormal vital signs, promptly notifying the RN supervisor. Despite the urgency, the LPN reported that it was not within her authority to initiate a hospital transfer and that she had to follow up multiple times with the supervisor. The supervisor assessed the resident, confirmed the abnormal findings, and began preparing transfer paperwork, which delayed the call to 911. The supervisor eventually contacted the physician, who instructed immediate transfer, but by this time, approximately forty-five minutes had elapsed from the initial recognition of the change in condition to the call for emergency services. Interviews with facility staff and review of policies revealed that the process for transferring residents to a higher level of care was not followed in a timely manner. The facility's policy and the expectations of the Medical Director and Director of Nursing indicated that emergency services should be contacted immediately in such situations, and paperwork should not delay transfer. However, in this case, the resident's transfer was delayed due to adherence to paperwork procedures and lack of prompt action, despite clear signs of a significant change in condition.
Penalty
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A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with Alzheimer’s disease and depression exhibited intermittent delusional statements, refusals of medications and care, and occasional yelling or suspiciousness toward staff over several months. Nursing notes documented these behaviors but did not show a comprehensive psychiatric assessment or evidence of a sustained major mood episode. A psychiatric NP subsequently added diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel, despite no prior history of schizoaffective disorder and no detailed evaluation in the record to support the new diagnosis. The resident’s representative reported no known mental health history or hospitalizations and was unaware of the schizoaffective disorder diagnosis, and the DON indicated there was no specific facility policy for schizoaffective disorder.
A nurse failed to follow professional standards and facility policy for medication administration by not properly verifying resident identity before giving scheduled medications. Two severely cognitively impaired roommates were involved; one had orders for oral morphine and levothyroxine, while the other did not. The RN called out one roommate’s name, but when the other responded, the RN proceeded to administer the morphine and levothyroxine without confirming identity using required methods such as the MAR photo or the 5 Rights of Medication Administration. The wrong resident subsequently developed hypotension and profound bradycardia, was sent to the ED, treated with naloxone for opioid poisoning, and diagnosed with accidental opioid poisoning.
The facility failed to meet professional standards of practice when staff did not clarify physician orders for oral medications for a resident who was documented as NPO with dysphagia, esophageal disease, and a gastrostomy. Despite the care plan indicating nothing by mouth, orders for prednisone and magnesium glycinate specified administration by mouth, and nursing staff did not verify or correct these routes before implementation, as required by professional nursing standards.
A resident with a documented Doxycycline allergy, noted in both a hospital after-care summary and the EMR allergy banner, was prescribed Doxycycline 100 mg BID for seven days after testing positive for an infectious disease. An RN texted the physician about the test result without the EMR open and entered the Doxycycline order, reporting no recall of an allergy alert. The physician, who did not have EMR access and relied on nursing staff to report allergies, was unaware of the allergy. A Guardian later identified the contraindicated order while reviewing the MAR. The DON stated nurses are expected to have the EMR open when contacting physicians, and the Administrator acknowledged that the physician ordered a medication to which the resident was allergic and that the nurse did not inform him of the allergy.
A resident with a stage 4 right hip pressure ulcer had physician orders for wound vac therapy at 120 mmHg suction, with specific cleaning and dressing change instructions. A wound consultant later recommended increasing the wound vac suction to 150 mmHg, but this change was never incorporated into the physician’s orders or the Treatment Administration Record. As confirmed by the DON, the consultant’s recommendations were not updated in the clinical record, resulting in the resident continuing on the original wound vac settings contrary to the consultant’s recommendation.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Unsubstantiated Schizoaffective Disorder Diagnosis and Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality when assigning a new diagnosis of schizoaffective disorder and initiating an antipsychotic medication for one resident without adequate supporting assessment or documentation. The resident’s clinical record showed existing diagnoses of Alzheimer’s disease, depression, borderline personality disorder, and delusional disorder, with prior PASSAR and admission MDS assessments reflecting depression and dementia/Alzheimer’s disease, and treatment with an antidepressant. Nursing progress notes over several months documented episodes of the resident reporting men causing trouble, believing a man was in her room, and talking about a man wanting to marry her and yelling through the walls, as well as frequent refusals of medications, blood sugar checks, blood pressure checks, insulin, and hygiene care. Additional nursing documentation described the resident as sometimes yelling at staff, being visibly upset by a room move, being leery of staff and asking to see name badges, and making statements that housekeeping had not cleaned her room or that she had not received medications when records indicated that she had. Despite these behaviors and delusional-type statements, there were no other documented behaviors in the nursing progress notes between late April and mid-July beyond refusals of care, expressions of dissatisfaction, and intermittent suspiciousness. The record did not contain a comprehensive psychiatric evaluation establishing that the resident had experienced a major mood episode of uninterrupted duration or otherwise met the diagnostic criteria for schizoaffective disorder. On a psychiatric NP visit for initial psychotropic medication management, the NP added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel 25 mg. The resident had no prior history of schizoaffective disorder, and the clinical record lacked an assessment to substantiate this new diagnosis. There was also no documentation that the resident’s mental health history was reviewed with the resident’s representative or that the delusional symptoms were evaluated as a possible progression of Alzheimer’s disease. The resident’s representative later reported that the resident had no known history of mental health disorders or psychiatric hospitalization and was unaware of the schizoaffective disorder diagnosis. The DON stated there was no facility policy specific to schizoaffective disorder and that the facility followed federal regulations.
Medication Error from Failure to Verify Resident Identity Before Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and medication administration were provided in accordance with professional standards of practice and facility policy, specifically the verification of resident identity prior to administering medications. Facility policy on “Medication Administration” required licensed nurses to verify resident identity, including use of the resident’s photograph in the MAR, and to administer medications as ordered and in line with professional standards. State nursing standards cited in the report required RNs to exercise sound nursing judgment, administer drugs as ordered, and follow accepted codes of behavior to assure safe and effective practice, including adherence to the 5 Rights of Medication Administration. Resident 50 and Resident 51 were cognitively impaired roommates, each with severe cognitive impairment as evidenced by low BIMS scores on recent MDS assessments. Resident 50 had physician orders for morphine sulfate oral concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg by mouth daily. Resident 51 had diagnoses including dementia with severe cognitive impairment. On the morning of the incident, an agency RN (Employee 1) entered the shared room, called out Resident 50’s name, and Resident 51 responded. The RN then approached Resident 51, identified the medications prepared for administration (morphine sulfate 0.5 ml and levothyroxine 25 mcg), received an “okay” response from Resident 51, and administered Resident 50’s medications to Resident 51. After leaving the room and returning to the computer to document, the RN realized the medications had been given to the wrong resident. The RN obtained Resident 51’s vital signs, which showed low blood pressure and bradycardia, and emergency services were contacted. Hospital records documented that Resident 51 arrived with abnormal vital signs, including a heart rate of 29 beats per minute and low blood pressure, was alert but disoriented, and was treated with two doses of naloxone for opioid poisoning and profound bradycardia. The resident was diagnosed with accidental opioid poisoning. In a subsequent interview, the RN acknowledged administering medication to the wrong resident and confirmed that she did not follow accepted medication administration practices or the 5 Rights of Medication Administration, leading to the resident receiving another resident’s opioid medication and experiencing adverse clinical effects requiring emergency medical treatment.
Plan Of Correction
1. Facility cannot retroactively correct deficiency as it relates to resident 51 on 4/6/2026 and a medication error. 2. Audited medication errors from 1/1/2026 to current to review root cause of errors. Results have been added to our education component for licensed nurses. 3. As outlined by the self-directed letter, AAE Consulting Services, approved by the Department of Health, will provide facility-wide education on the program called "Professional Standards and Significant medication error standards as well as federal regulations and accompanying guidelines. Education will be provided by AAE Consulting Services to conduct the directed in-service sessions on 4/23/26. Anyone that is unable to attend the 4/23/26 sessions will be required to be completed prior to their next scheduled working shift. A copy of the in-service will also be added to agency orientation documents for review prior to working a shift within the facility. All residents who did not refuse have been issued wrist bands for a secondary identification. Wrist band checks added to residents' TAR per shift to check for placement. All resident pictures for primary identification have been uploaded in their respective EMR's on 4/9/2026. 4. Facility education will be completed biannually with licensed nursing staff for the 5 rights of medication verification. Education will be included in all new licensed nursing staff education during the initial orientation process upon hire. Educations will be audited monthly by the DON/designee and forwarded to the QA committee to ensure compliance with resident identification during medication passes. 5. April 25, 2025
Failure to Clarify Oral Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure physician orders met professional standards of quality by not clarifying medication routes for a resident who was NPO and had swallowing difficulties. Record review showed that a resident readmitted with dysphagia, disease of the esophagus, and a gastrostomy had a nutritional care plan, revised 4/3/26, documenting the resident was NPO (nothing by mouth). Despite this, physician orders directed that prednisone 5 mg be given by mouth daily for renal insufficiency and magnesium glycinate 100 mg be given by mouth at bedtime for insomnia. According to the National Council of State Boards of Nursing, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. On 4/2/26 at 11:32 AM, the DON and CRN confirmed that the resident does not take anything by mouth and acknowledged that the provider’s orders should have been clarified prior to implementation. This failure created the potential for harm if the resident were to receive oral medications despite having difficulty swallowing.
Allergic Resident Prescribed Contraindicated Antibiotic
Penalty
Summary
A resident with a documented allergy to Doxycycline, causing shortness of breath, was prescribed this medication despite the allergy being clearly listed in multiple parts of the medical record. The hospital after-care summary and the allergy section on the resident’s EMR banner both identified Doxycycline as an allergen. On 1/19/2026, after the resident tested positive for an infectious disease, a nurse contacted the physician via text message about the positive test result without having the EMR open to review allergies. The physician responded by ordering Doxycycline 100 mg twice daily for seven days, and the nurse transcribed this as a telephone order in the EMR. The nurse later stated she did not recall any allergy alert appearing when she entered the order. The physician reported he was unaware of the resident’s Doxycycline allergy and did not have access to the EMR, stating that nursing staff typically inform him of allergies. Another nurse explained that allergies are displayed beneath the resident’s name in the EMR and that an alert appears when a contraindicated medication is entered. The resident’s Guardian discovered the Doxycycline order while reviewing the MAR and notified the facility of the known allergy. The DON stated that nurses are expected to have the EMR open when contacting physicians so they can review allergies, and the Administrator acknowledged that the physician prescribed a medication to which the resident was allergic and that the nurse did not inform the physician of the allergy when the medication was prescribed.
Failure to Implement Wound Consultant’s Recommendation for Wound Vac Settings
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that wound consultant recommendations were reviewed with and incorporated into the attending physician’s orders for a resident. The resident’s annual MDS assessment dated February 24, 2026, documented that the resident was cognitively intact and had a stage 4 pressure ulcer on the right hip. Physician’s orders dated March 10, 2026, directed staff to clean the right hip wound and surrounding tissue with soap and warm water, rinse with saline, and apply a wound vac, ensuring black foam was placed into the tunneling, with dressing changes scheduled for Monday, Wednesday, and Friday, and suction set at 120 mmHg. A wound consultant note dated March 20, 2026, documented that the same resident’s stage 4 right hip pressure ulcer required a change in wound vac suction from 120 mmHg to 150 mmHg. Review of the resident’s March 2026 Treatment Administration Record showed that, as of March 31, 2026, the recommended change in wound vac suction had not been initiated. In an interview on March 31, 2026, at 12:25 p.m., the Director of Nursing confirmed that the wound care recommendations made by the wound care clinic on March 20, 2026, had not been updated in the resident’s clinical record as of that date, resulting in the failure to meet professional standards of nursing services as required by state regulations.
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