F0684

G

Failure to Follow Provider Orders for ED Transfer and Accurate Medication Administration

Eugene, Oregon Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and properly act on critical lab values and medication orders for three residents. For one resident with multiple spinal fractures and kidney disease, a critical low red blood cell count was reported to the facility, and the on‑call physician conducted a virtual assessment and ordered the resident sent to the ED via non‑emergent transport for possible blood transfusion. The LPN who received the critical lab and the order did not enter the ED transfer order into the chart, did not act on the transport order, and did not document the provider’s verbal order at the time. She instead wrote a note the following day. Another LPN coming on to the next shift overheard the provider instructing that the resident be sent to the ED and that family be called, but she was not informed of the critical lab or the need to complete the transfer and assumed, without confirming, that the resident had refused transfer.

During the evening, the second LPN administered nausea medication twice and was informed by a certified occupational therapy assistant that the resident had low blood pressure, changes in cognition, increased fatigue, nausea, and pale skin. The LPN instructed the assistant to give the resident water and retake the blood pressure, and when the repeat blood pressure was reported, she stated she was no longer concerned and did not assess the resident despite the reported symptoms. The resident remained in the room and was not sent to the ED as ordered. A subsequent progress note documented that the resident died early the next morning. The Director of Nursing Services later acknowledged that the nurse who received the critical lab did not write a timely progress note, did not enter the verbal order to transport the resident to the ED, did not act on the transport order, and did not document the provider’s verbal order at the time of the incident.

The deficiency also includes two separate medication error issues. One resident admitted with sepsis had a physician order for Cefazolin every eight hours, but the order was transcribed as ceftriaxone, and the resident received the wrong antibiotic 11 times, as documented in the MAR and a facility report of incident. Another resident with PTSD had a physician order for quetiapine 100 mg in the morning and at bedtime; during a care conference for gradual dose reduction, it was noted that the resident had been administered more quetiapine than ordered. The orders were changed to 300 mg at bedtime with discontinuation of the 100 mg morning dose, but the morning dose was not discontinued, resulting in continued administration beyond the revised order. The DNS acknowledged the medication administration errors for both residents.