Failure to Implement Physician Order for Stool Sample Collection
Penalty
Summary
The facility failed to implement a physician’s order for a sampled resident, resulting in a missed diagnostic test. Clinical record review showed that Resident 1, who had diagnoses including hypertension and muscle weakness, had a verbal physician order dated January 23, 2026, directing staff to collect a stool sample to rule out Clostridium difficile. Review of the clinical record revealed no documented evidence that the ordered stool sample was ever collected. In an interview on January 27, 2026, at 3:15 p.m., the Director of Nursing confirmed that the stool sample had not been collected as ordered. This deficiency was cited under CFR 483.25 Quality of Care and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, and was noted as previously cited on December 19, 2025.
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