Failure to Assess and Respond to Repeated Chest Pain Complaints After Acute Change in Condition
Summary
The deficiency involves the facility’s failure to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with significant cardiac history. The resident had diagnoses including acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. The admission MDS showed the resident had intact memory, modified independence for decision-making, and required varying levels of assistance with ADLs. Physician orders included PRN Maalox for antacid use, but there were no PRN orders for chest pain. On the night in question, the resident repeatedly used the call light beginning around 11:07 P.M. and continuing into the early morning hours. CNA staff reported that the resident complained multiple times of chest pain and chest tightness and appeared to be in distress. CNA #208 stated the resident first complained of not having had a bowel movement since the hospital, was assisted with a bedpan, and later had a large bowel movement. About 20 minutes after that, the resident complained of chest pain, which CNA #208 reported to RN #207. CNA #208 stated the nurse did not get up right away, and after another call light and another complaint of chest pain, she again informed RN #207, who responded that she had given Maalox and the resident needed to give it time to work. CNA #208 and other CNAs reported that the resident continued to ring the call light approximately every 20 minutes, repeatedly complaining of chest pain and, at one point, chest tightness. CNA #136 and CNA #153 also reported that the resident complained of chest tightening or chest tightness and looked like he was in distress, and they informed RN #207. RN #207 stated that when informed of the complaint, she reviewed the physician’s orders, saw only PRN Maalox, and then went to see the resident. She reported that the resident described indigestion, that she administered PRN Maalox, and that she took his blood pressure, which was initially elevated and then normal after repositioning, but she did not document these vital signs or an assessment in the medical record. The eMAR showed Maalox was administered at 12:28 A.M., but there was no documentation of an assessment, vital signs, or chest pain at that time. The device activity report showed multiple call light activations between 11:07 P.M. and 12:48 A.M. RN #207 later documented at 4:21 A.M. that the Maalox was effective, but there was no corresponding assessment or vital signs documented. She stated that at some point she saw the resident sleeping and did not recall the time. Around the time of her medication pass, she noticed the resident did not look right, entered the room, and found him unresponsive, at which point 911 was called and CPR initiated. The EMS run report documented that EMS was dispatched shortly after 5:14 A.M. and arrived to find the resident unresponsive, not breathing, pulseless, with rigor mortis in the jaw and mottling throughout the body. Nursing staff told EMS that the resident had complained of chest pain earlier in the night and that they had checked on him at 4:00 A.M. The resident was wearing a Full Code wristband, and EMS confirmed asystole in multiple leads before a physician pronounced death at 5:28 A.M. Review of the facility’s Acute Condition Changes-Clinical Protocol showed that nurses are to assess and document baseline information such as vital signs, pain level, and changes in condition, and that direct care staff are to be trained to recognize and report significant changes to the nurse. Despite this policy, there was no documented evidence that the resident’s repeated complaints of chest pain and tightness were adequately assessed, that vital signs and assessments were documented, or that the physician was notified of the change in condition, leading to the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals following an acute change in condition.
Removal Plan
- Remove RN #207 from work.
- Review the change in condition policy with the DON and Administrator before staff education.
- Review records of all residents for changes in condition to ensure they are properly reported and addressed.
- Run a report for all residents with cardiac diagnoses and review for any need for reassessment or recent change in condition.
- In-service all certified nursing assistants (CNA) on the need to immediately notify the nurse if there is a change in condition or emergency and on the facility protocol for obtaining assistance during an emergency situation, including what to do if a nurse is unavailable or not responding.
- Instruct CNAs to escalate up the chain to the charge nurse or DON if a nurse is unavailable or not responding.
- Do not permit any CNA to work until in-servicing is completed.
- In-service all licensed nurses on the facility policies and procedures related to change in condition, appropriate assessments and documentation, timely notification to physician of change in condition, and how to respond to emergency situations.
- Do not permit any licensed nurse to work until in-servicing is completed.
- Hold an ad hoc QAPI meeting with the Medical Director, Administrator, DON, and nursing staff to discuss the incident, follow-up measures and action plan, and to review relevant policies.
- Begin monitoring all shift reports and nurse's notes to ensure all changes in condition are timely reported to the physician and appropriately addressed.
- Conduct audits daily for two weeks and then three times a week for six weeks.
- Have the QA Committee monitor the results of the audits and follow up as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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