Failure to Obtain Hospice Order and Follow Diabetic Medication Orders
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident receiving hospice services. One resident with diagnoses including aphasia, dysphagia, dementia, Alzheimer’s disease, and pulmonary embolism was admitted to the facility and later had a physician order dated 11/17/25 to be referred to hospice for dementia. Nursing progress notes documented that hospice services began on 11/18/25, and the resident’s care plan initiated on 11/11/25 indicated the resident was admitted to hospice for a terminal prognosis and multiple comorbidities. However, the quarterly MDS dated 11/20/25 indicated the resident was not receiving hospice services, and there was no active physician order for hospice care in the record, which the DON confirmed should have been present for any resident admitted under hospice care. The facility also failed to follow physician orders for a resident with Type 2 Diabetes Mellitus. The resident’s comprehensive care plan dated 10/21/24 documented an intervention to increase Metformin from 500 mg to 1,000 mg daily, and a physician order dated 12/16/25 specified Metformin 1,000 mg. During an observation on 12/17/25, an RN administered only one 500 mg tablet of Metformin instead of the ordered 1,000 mg dose. In a subsequent interview, the RN acknowledged not following the physician’s order when administering the medication, and the DON confirmed that nursing staff are expected to follow physician orders and administer the correct medication dose.
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