F0684

G

Failure to Follow NP Orders and Respond Timely to Resident’s Change in Condition

Torrance, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered and needed treatment and care to a resident who experienced a significant change of condition, including prolonged vomiting and severe pain. The resident had multiple complex diagnoses, including alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia, and cervical spine disorders, and was dependent for all ADLs. According to progress notes, the resident had been vomiting for three days by 11/21 and reported generalized and abdominal pain rated 10/10, refused medications such as gabapentin and lactulose due to fear of vomiting, and was placed NPO except for sips of water. Despite these symptoms, there was no timely initiation of a change of condition (COC) evaluation or care plan to address the vomiting and pain, and nursing assessments (including description of vomitus, abdominal assessment, and vital signs) were either incomplete or undocumented.

The facility did not follow the NP’s texted orders for pain management and transfer to the hospital, and did not document those orders in the medical record. On 11/21, the NP instructed via text to use a Tylenol suppository, warm compresses to the abdomen, and repositioning for the resident’s 10/10 abdominal and arm pain with three days of vomiting; these interventions were not documented as implemented. On 11/22 at 1:35 p.m., the NP texted an order to transfer the resident immediately to a GACH for MRI and further evaluation due to ongoing vomiting, 10/10 abdominal and arm pain, concern for dehydration, and possible esophageal varices. This transfer order was not entered into the EHR, not carried out, and not documented in the resident’s record. Instead, staff reported that the DON advised not to transfer the resident and to start IV fluids and STAT labs, and the NP later texted that if the DON was taking over the case, staff should follow the DON’s direction while completing IV hydration and STAT labs and monitoring the resident.

The facility also failed to ensure timely completion of STAT laboratory tests and to follow its own policies on change in condition and transfer. The NP ordered STAT CBC, CMP, lipase, and lactate on 11/22 at 7:13 p.m., but IV fluids were not started until 8:00 p.m., and the STAT labs were not drawn until 8:00 a.m. the next day, approximately 13 hours after the orders were received, despite staff acknowledging that STAT labs should be completed within four hours. The COC evaluation for vomiting was not initiated until 11/22, two days after vomiting began, and there was no COC or care plan initiated for the resident’s 10/10 pain on 11/21. The facility’s transfer/discharge and change-in-condition policies required prompt physician notification and transfer when the resident’s needs could not be met in the facility, but the resident was not transferred until the evening of 11/23, after vomiting blood and reporting severe esophageal pain with red-colored vomitus. This sequence of inactions and delays resulted in a 30-hour delay in transfer from the time the NP first ordered immediate transfer on 11/22 at 1:35 p.m.

Additional interviews and record reviews further demonstrated the deficiencies in assessment, monitoring, and documentation. CNAs reported observing multiple vomiting episodes and notifying licensed staff, with the resident complaining of nausea and worsening abdominal pain, while the resident continued to refuse medications due to fear of vomiting. LVN 3 acknowledged that there was no documented assessment of the vomitus (color, smell), abdominal status, or vital signs, and that no COC report or care plan was initiated, stating that lack of documentation meant the assessment was not done and that the resident was not closely monitored. RNS 3 confirmed that vomiting began on 11/20, that the COC was delayed until 11/22, that the NP’s transfer order on 11/22 was not entered into the EHR or carried out, and that the delay in following the NP’s orders placed the resident at risk for harm. The DON acknowledged that there was no COC initiated for vomiting until 11/22, no COC for the 10/10 pain on 11/21, and no care plan for vomiting and pain, despite facility policies requiring prompt response to significant changes in condition and transfer when the resident’s needs could not be met in the facility.

The facility’s own policies titled “Change in a Resident’s Condition or Status” and “Transfer or Discharge” required prompt notification of the attending physician and resident/representative when there was a significant change in condition, and transfer when necessary for the resident’s welfare and when needs could not be met in the facility. The documented events show that although the NP was notified and issued orders for NPO status, pain interventions, IV fluids, STAT labs, and immediate transfer, these orders were not consistently implemented, documented, or acted upon in a timely manner. The resident ultimately was transferred to the hospital after vomiting blood and reporting severe pain, where she was treated for hematemesis, minimal esophageal varices, gastritis, and ascites requiring therapeutic paracentesis and blood transfusion. The deficiency centers on the facility’s failure to follow provider orders, to timely assess and respond to a clear change in condition, to complete STAT diagnostics promptly, to create and implement a person-centered care plan with measurable interventions, and to adhere to its own transfer and change-in-condition policies.

These failures resulted in a 30-hour delay in transferring the resident to the GACH from the time the NP gave the transfer order on 11/22/2025 at 1:35 p.m.