Failure to Notify MD, Complete Ordered UA, Monitor for Dehydration, and Report Delayed Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received treatment and care in accordance with professional standards of practice during multiple changes of condition. The resident, who had diagnoses including metabolic encephalopathy and oropharyngeal dysphagia and was assessed as having severe cognitive impairment and dependence in ADLs and mobility, experienced a change of condition on 12/18/2025 when she refused breakfast and lunch and allowed food to fall from her mouth. A family member reported this pattern occurred when the resident developed a UTI and requested a urinalysis (UA), which the MD ordered. However, the change of condition documentation and progress notes did not show that the MD was informed of the resident’s refusal to eat or the food falling from her mouth. On 12/18/2025, the resident’s care plan was updated with a problem of decreased or inability to eat/drink adequate amounts related to refusing meals and allowing food to fall from her mouth, with an intervention to assess the resident for dehydration. Review of the clinical record from that date showed no documentation that the resident was monitored or assessed for dehydration as care-planned. Additionally, although progress notes on 12/19/2025 indicated a urine specimen was collected, the lab report dated 12/22/2025 did not contain a UA result, and later information from the contracted lab indicated no urine specimen had been collected on 12/18/2025. The DON acknowledged there was no UA result in the record and that the specimen may not have been collected, despite the MD’s order. On 12/22/2025, the resident had another change of condition with poor meal intake, pocketing food, and abnormal lab results, and the MD ordered transfer to a general acute care hospital (GACH) for evaluation. Progress notes documented that the GACH had no available bed and later that the GACH ED could not admit the resident due to saturated admissions, and subsequent notes into the early morning of 12/23/2025 indicated the resident was still waiting for transfer. There was no documentation that the MD was notified of the delay in transfer or that additional orders were obtained while the resident remained in the facility. During interviews, the LVN and DON confirmed there was no documented evidence of MD notification regarding the 12/18/2025 change of condition, no documentation of dehydration assessment as care-planned, no UA result due to lack of specimen collection, and no MD notification when the hospital could not accept the resident as ordered.
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