F0684

D

Failure to Accurately Assess, Treat, and Document Changes in Condition and Hospice Services

Bloomfield Hills, Michigan Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves failures to complete accurate assessments, document and act on vital signs and lab results, administer ordered medications and IV fluids, and communicate accurate clinical information to physicians for timely treatment or transfer, as well as failures in hospice communication and documentation. For one resident with dementia, seizures, and total dependence for ADLs, nursing staff documented a change in condition with shortness of breath and declining SpO2 after the spouse reported the resident did not look well and requested hospital transfer. The spouse reported that the physician initially refused transfer and threatened the nurse’s job, and that staff had difficulty obtaining accurate blood pressure readings. A photograph taken by the spouse showed a BP of 215/160, which the assigned RN confirmed seeing but did not document, stating they believed it was inaccurate and did not obtain a manual confirmation. The vital signs entered in the record instead showed a BP of 100/61, pulse 79, respirations 22, and SpO2 91% without a temperature, and the RN could not explain why a full set of vitals, including temperature, was not obtained or why the more abnormal values were not documented. EMS later documented the resident as hypoxic with SpO2 80% on room air, tachycardic at 140 bpm, hypotensive, febrile at 101.4°F, and with rhonchi in all lung fields, and the hospital documented sepsis, hypotension, tachycardia, and high fever on admission.

For a second resident with coronary heart disease, schizophrenia, type II diabetes, and intact cognition, nursing notes documented nausea, vomiting, and poor oral intake, with an SBAR indicating a change in condition and a recommendation for blood tests. Labs drawn on one day showed elevated WBC and low RBC and hemoglobin, and were placed in the physician log and faxed, but there was no documentation that the physician reviewed the results or issued new orders. Subsequent notes documented a nosebleed and an order for a CBC for the following Monday, but no additional blood pressure readings were recorded on the day the resident was transferred to the hospital. EMS documented that the resident had hypotension persisting for three hours, with a reported BP of 80/59 prior to EMS arrival, and the hospital documented dehydration, low blood pressure with initial readings in the 50s and 70s/40s, a week of not eating or drinking, and vomiting. The agency nurse who arranged the transfer reported that they had difficulty obtaining blood pressures with two different machines, recalled one low reading but could not recall the value, and stated they were not aware of the prior vomiting and bleeding because, as an agency nurse, not all information was provided.

For a third resident with cerebral infarction, acute respiratory failure with hypoxia, and hemiplegia, nursing notes documented a change in condition with audible fluid in the lungs, cough, elevated BP, and low-grade fever, with Tylenol and IM Lasix administered and the physician and family notified. Subsequent notes described shortness of breath and tachycardia, with an NP assessment of acute respiratory failure, multiple wounds, pneumonia, and decreased responsiveness, and orders to monitor vitals, SpO2, and for labs (CBC and CMP). The record contained no results for the ordered labs. Another NP note documented tachycardia, tachypnea, diminished breath sounds, a temperature of 99.6°F, heart rate 114, SpO2 98% on 3L, and an order for a 1L normal saline IV fluid bolus, but the MAR/TAR showed no documentation that the IV bolus was administered. A later MD note ordered a 1L normal saline IV bolus at 80 cc/hr and an increase in metoprolol to 50 mg twice daily, while the MAR/TAR showed that the new 50 mg dose was given in addition to the existing 25 mg twice daily, resulting in 75 mg twice daily being administered. Nursing notes documented episodes of shortness of breath, SpO2 dropping to 88% on 3L, and later to below 85% despite increasing oxygen to 5L and then a non-rebreather at 15L, with RR 26–30 and BP 168/89, but there was no documentation of the breathing treatments the RN stated were given, no physician order for those treatments, and no documentation of exact SpO2 values during the decline. The RN reported calling the physician and leaving a message without a callback, providing an undocumented breathing treatment without an order, and then calling 911; EMS found the resident unresponsive with GCS 3, SpO2 59% on NRB at 15L, respirations 30, and bilateral rales.

The deficiency also includes failure to ensure hospice communication and care were provided and appropriately documented for a resident with anorexia, type II diabetes, dementia, and severe cognitive impairment who had an order to be admitted to hospice. The resident’s care plan identified a hospice focus with an intervention to collaborate with the hospice company and specified hospice visits with days and services. When asked, an RN located a thin binder near the nurse’s station, but the documents did not include the names and dates of hospice representatives visiting the resident. During an interview and record review with the DON and corporate clinical support nurse, hospice reported that the resident was to receive weekly visits from both a nurse and a CNA, and provided the caregivers’ names. However, front desk staff could not locate any hospice CNA sign-in sheets for the prior three weeks, and the corporate clinical support nurse stated it would be in the resident’s best interest to obtain new hospice services because the current hospice was not performing necessary visits. The facility’s hospice policy required that hospice provide the most recent hospice plan of care, that the facility communicate with hospice and document such communication, and that hospice information be available within the facility, but the documentation and sign-in records for this resident’s hospice services were incomplete or missing.

Additionally, the surveyors requested an audit of actual administration times for the third resident’s January medications to clarify whether ordered treatments, including IV fluids and metoprolol dosing, were administered as scheduled. Multiple requests were made to the DON, administrator, and corporate clinical support nurse throughout the day, but the facility repeatedly reported that they did not have access to the audit data and did not provide the requested audit before the end of the survey. The facility’s change in condition policy required nurses to notify the physician when there is a significant change in physical status or a need to alter medical treatment, and to document assessments, notifications, interventions, and responses, but the records for the residents with changes in condition contained missing or incomplete vital signs, undocumented or uncompleted labs and treatments, and incomplete documentation of physician communication.