Failure to Review and Verify Medication Orders Results in Severe Medication Error
Summary
A deficiency occurred when the facility failed to ensure that a physician properly reviewed and verified medication orders for a resident admitted with multiple complex diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. Upon admission, the resident's medication orders for Carbidopa/Levodopa and Levothyroxine were transposed, resulting in the resident receiving incorrect dosages and frequencies of both medications. The error was not identified or corrected by the admitting nurse, the physician assistant, or the physician, despite documentation indicating that the medication orders were outside the recommended dosing regimen and pending confirmation. The resident, who was ambulatory and able to care for themselves upon admission, experienced a significant decline during their stay. The medication administration record showed that the resident received multiple extra doses of Levothyroxine over several days, totaling 2800 mcg within a 96-hour period. Progress notes and interviews revealed that the resident became confused, disoriented, unable to ambulate, and exhibited signs consistent with thyroid storm, such as elevated temperature, tachycardia, and altered mental status. Family members and the medical examiner confirmed the resident's rapid deterioration and the facility's admission of the medication error. The review of the resident's records indicated that the transcription error was made by the RN/Unit Manager and confirmed by the same nurse. The physician assistant noted the need to confirm the dosing but did not discontinue or correct the erroneous orders. The medical director stated that the physician assistant should have changed the orders and that the pharmacist and nursing staff should have recognized the error, as Levothyroxine is typically administered once daily in the morning. The failure to properly review, verify, and correct the medication orders directly resulted in the resident's severe adverse effects and subsequent death.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Physician progress notes were not completed, signed, or dated as required for 3 residents. The MRD confirmed that each resident’s most recent physician note was well past due, and the record included unsigned, draft, late-entry, and cloned notes that did not reflect a current review of the resident’s total plan of care, medications, treatments, or overall condition. One resident with intact cognition said they had not been seen by a facility physician since admission, while another resident with severe cognitive impairment had similarly outdated physician documentation.
Physician telephone orders were not signed within the required timeframe for two residents. One resident had multiple unsigned orders for post-op eye drops, wound care, meds, and treatment for oral thrush, while another resident had unsigned orders for PT/OT, BP meds with hold parameters, lab work, and peri-procedure medication holds. The ADON acknowledged the orders were not signed per facility policy, and the DON and Administrator were informed.
A resident was observed coughing and having difficulty swallowing while eating, and the NP ordered a swallow test, diet change, and chest x-ray. A later physician note focused on a pre-op H&P and did not address the swallowing change, the diet order, the chest x-ray, or the swallow evaluation order.
Physician notes were not timely signed or individualized for a resident who had a fall and was hospitalized with a subdural hematoma. The attending MD documented repeated, identical notes, including a readmission note that stated the resident had “no acute injury,” and the notes were signed days after they were created, delaying implementation of any updates to the resident’s care.
Physician progress notes were not written, signed, and dated at the time of the visit for three residents reviewed. The records showed multiple MD visits for residents with diagnoses including COPD, DM II, dementia, anxiety, depression, and osteomyelitis, but the notes were signed days later rather than at the time of the visits. The facility policy required documentation to include the date and time provided and the signature and title of the individual documenting.
A resident’s physician/provider did not review the total program of care, including meds and treatments, and monthly orders were not fully signed and dated. Record review showed missing signed monthly orders and a provider note that did not include all orders such as dietary supplements, wound care tx, bladder scans, and tubi grips; the DON and NHA acknowledged the visit note did not cover all orders being reviewed.
Physician Progress Notes Not Completed or Signed as Required
Penalty
Summary
The facility failed to ensure the attending physician reviewed each resident’s total program of care and failed to write, sign, and date progress notes as required for 3 of 12 sampled residents. The report states that this failure had the potential to result in residents not receiving timely evaluation of their medical regimen and necessary adjustments to treatments, placing them at risk for unmet medical needs and a decline in physical, mental, or psychosocial well-being. For Resident 1, the EHR showed a BIMS score of 14 and the most recent physician progress note was dated 03/16/2026, which was 101 days before the survey interview. The MRD confirmed that this was the latest physician progress note in the record. The facility also provided history and physical notes for 2022 and 2023 that did not identify the author’s credentials. A 04/16/2026 acute skilled nursing facility visit note remained unsigned and open, did not reflect the resident’s overall program of care, and was not available during the concurrent interview and record review. A 06/08/2026 LTC SNF monthly progress note was identified as a physician encounter, but much of its content appeared to be cloned from the 03/16/2026 progress note and the 05/14/2026 annual history and physical. For Resident 2, the EHR showed a BIMS score of 11 and the most recent physician progress note was dated 01/19/2026, which was 157 days before the survey interview. The MRD confirmed that this was the latest physician progress note in the record. The record also included an unsigned annual history and physical note dated 11/15/2024 that remained in draft status with a later draft timestamp, and multiple physician progress notes and LTC SNF monthly notes that were entered as late entries or remained unsigned and in draft status. For Resident 3, the EHR showed a BIMS score of 6 and the most recent physician progress note was dated 03/03/2026, which was 114 days before the survey interview. The MRD confirmed that this was the latest physician progress note in the record. Resident 3 stated during interview that they had not been seen by a physician at the facility since becoming a resident, though they had seen physicians outside the facility several times. The 02/28/2026 and 03/03/2026 SNF progress notes were identified as physician encounters, but both appeared to be cloned from earlier notes.
Physician Telephone Orders Not Signed Timely
Penalty
Summary
The facility failed to ensure the physician signed telephone orders in a timely manner for two sampled residents. Facility policy titled Physician Orders and Telephone Orders stated that telephone orders shall be signed within five days by the prescribing physician or extender as permitted by law. For Resident 6, who was admitted and later readmitted to the facility and whose H&P dated 2/6/25 showed the resident could make needs known but was not capable of making own medical decisions, multiple telephone orders lacked physician signatures, including orders dated 5/27/26 for ophthalmic medications after eye surgery, 6/9/26 for wound care to the right posterior skin tear, 6/16/26 for finasteride and mycophenolate mofetil, 6/17/26 for clobetasol ointment to both feet and the left palm, and 6/19/26 for nystatin suspension for oral thrush. For Resident 41, who was admitted to the facility and whose H&P dated 4/23/26 showed the resident could make needs known but was not capable of making own medical decisions, several telephone orders also lacked physician signatures. These included orders dated 5/21/26 for physical therapy, 5/28/26 for metoprolol tartrate with hold parameters, 6/16/26 for occupational therapy, and 6/17/26 for continued physical therapy, lab tests, holding medications before a procedure, and holding Eliquis before a procedure. During an interview and concurrent record review on 6/25/26, the ADON acknowledged the physician's orders were not signed as required by facility policy, and the DON and Administrator were informed and acknowledged the findings.
Physician Note Did Not Address Resident’s Swallowing Change in Condition
Penalty
Summary
The facility failed to ensure a physician's medically necessary visit addressed a resident's change in clinical status related to swallowing difficulties and the related follow-up orders. Resident #1 was observed coughing and having difficulty swallowing while eating lunch, and the resident stated that he/she was having difficulty swallowing. The NP was notified and ordered a speech-language pathologist swallowing test, a diet change to mechanical soft/chopped meat, and a chest x-ray. However, a physician progress note completed several days later documented a pre-op history and physical for a bilateral retrograde pyelogram and did not address the resident's swallowing change in condition, the diet change, the chest x-ray, or the swallowing test order. During interview, the Administrator and DON were informed of the concern regarding the lack of physician documentation related to the resident's swallowing risks and follow-up for the swallowing evaluation.
Physician Notes Were Not Timely Signed or Individualized
Penalty
Summary
The physician failed to have signed progress notes and orders entered timely after seeing the resident, and the notes were not individualized to reflect the resident’s actual condition. Review of the medical record for Resident #7 showed attending notes by Attending #21 on 5/20, 6/1, and 6/17, and all three notes contained the same information. After Resident #7 sustained a fall on 5/31/26 and was hospitalized with a subdural hematoma, the 6/1/26 readmission note stated the resident had “no acute injury” and included a plan for 24/7 supervision. The record also showed that the physician notes were signed on dates later than when they were created. The 5/20/26 history and physical was signed on 5/24/26, the 6/1/26 readmission note was not signed until 6/10/26, and the 6/17/26 progress note was signed on 6/18/26. During interview, Attending #21 reviewed the notes and the resident’s status and stated it was her “fault” that the note was not comprehensive and did not capture the resident’s actual status.
Physician Progress Notes Not Signed and Dated at Time of Visit
Penalty
Summary
The facility failed to ensure the physician progress notes were written, signed, and dated at the time of the visit for three residents reviewed for physician visits. Resident #33 was admitted with diagnoses including COPD, bipolar disorder, depression, and type II DM, and had intact cognition with a BIMS score of 15. The medical record showed physician visits on 04/01/26, 05/01/26, and 05/27/26, but the corresponding progress notes were not written and signed by MD #100 until 04/19/26, 05/03/26, and 05/29/26. During interview, the RDCS verified the notes were not signed at the time of the visits. Resident #50 was admitted with diagnoses including acute respiratory failure with hypoxia, DM II, dementia, and anxiety disorder, and had intact cognition with a BIMS score of 14. The record showed physician visits on 04/01/26, 04/08/26, 05/01/26, and 05/08/26, but the notes were not written and signed by MD #100 until later dates in April and May. Resident #62, who had diagnoses including DM II, osteomyelitis of the right ankle and foot, depression, and venous insufficiency and had intact cognition with a BIMS score of 15, also had physician visits on 03/18/26, 04/01/26, 04/11/26, and 05/01/26 with progress notes signed after the visits. The facility policy titled, Charting and Documentation, required documentation to include the date and time provided and the signature and title of the individual documenting.
Physician Orders Not Fully Reviewed or Signed
Penalty
Summary
The facility did not ensure the physician or provider reviewed the resident’s total program of care, including medications and treatments, and did not ensure all orders were signed and dated for one resident. Record review showed that R5 was missing signed monthly physician orders for January, February, April, and May of 2026, and the surveyor was unable to locate signed monthly physician orders during the record review on 6/18/26. The surveyor obtained a physician order report dated 2/6/26 to 3/6/26 that was signed by the resident’s provider, and a physician assistant encounter note dated 1/5/26 that did not include all of R5’s orders or total program of care. The note did not include orders for dietary supplements, wound care treatments, bladder scanning, or tubi grips. During interview, the DON stated monthly MD orders are printed for provider rounds and uploaded into the EMAR each month, but acknowledged the visit note did not include all orders being reviewed and that provider visits did not address treatment orders, supplements, blood sugar checks, tubi grips, or bladder scans. The DON and NHA also indicated that all orders should be included in the order review.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.