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F0684
G

Failure to Implement Physician Orders and Provide Wound Care

Metropolis, Illinois Survey Completed on 11-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that physician orders were accurate and implemented for residents following hospitalization and changes in condition, as well as failed to assess and treat lymphedema and wounds per physician orders for three residents. For one resident with a history of acute respiratory failure, COPD, heart failure, and other comorbidities, the facility did not update or implement new orders for furosemide (Lasix) and albuterol as prescribed upon discharge from the hospital. The resident's hospital records indicated a new diagnosis of congestive heart failure and a change in furosemide from as-needed to daily dosing, but the facility continued to administer the medication only as needed. Additionally, the resident's albuterol nebulizer dosage did not match the hospital's discharge instructions, and there was no documentation of a required follow-up physician visit. The resident repeatedly reported difficulty breathing and requested breathing treatments, which were not consistently provided according to orders, and staff failed to assess or respond appropriately to her complaints. Documentation was inconsistent and did not reflect the resident's actual condition, and the nurse practitioner was not notified of the new diagnosis or medication changes due to lack of communication and updates in the electronic health record. Another resident with lymphedema, reduced mobility, and CHF had physician orders for daily compression wraps, wound care, and use of a lymphedema pump. The facility failed to consistently perform and document wound and skin assessments, including measurements and descriptions of wounds, and did not monitor weights to track lymphedema. The resident reported that dressing changes and compression wraps were frequently not performed, sometimes due to lack of supplies such as ace wraps, and staff confirmed that wound care supplies were often unavailable. When the resident refused treatments because they were not performed as she preferred, staff did not notify the physician or nurse practitioner of these refusals, nor did they document or address the resident's requests for alternative treatments. The lack of proper wound care and monitoring led to the resident developing redness, swelling, and altered mental status, resulting in hospitalization for cellulitis and septic shock. Throughout the report, there were multiple instances where staff failed to follow the facility's own medication administration policy, which requires accurate documentation and implementation of physician orders, as well as prompt reporting of changes in condition. There was also a lack of a significant change in condition policy, and communication breakdowns between nursing staff, administration, and medical providers contributed to the deficiencies. The failures resulted in significant discomfort, anxiety, and adverse health outcomes for the residents involved.

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