Failure of Physician Oversight and Timely Response to Worsening Venous Leg Ulcer
Summary
The deficiency involves the failure of the Medical Director/attending physician to effectively oversee, supervise, and assess a resident’s medical care in relation to a worsening right lower leg venous stasis ulcer. The resident was admitted with diagnoses including a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, and had severe cognitive impairment with a responsible party designated for decision‑making. An order was in place for wound evaluation and treatment by an outside wound care company, and weekly skin assessments documented the wound’s status. On one weekly assessment, the wound nurse documented that the right lower leg venous ulcer measured approximately 15 cm x 5 cm x 0.4 cm post‑debridement, with 50% slough and 50% granulation tissue, significant drainage, no odor, no signs or symptoms of infection, and that the wound was showing improvement. On a subsequent weekly assessment, the wound nurse documented that the same wound was worse, with the same measurements but now 100% slough/necrotic tissue and heavy drainage, though still noted as having no odor and no signs or symptoms of infection. During wound rounds on that later date, the wound doctor evaluated the resident’s right lower leg ulcer, determined that bedside wound care was not effective, and recommended hospital admission for operative debridement and possible above‑ and below‑knee amputation. The wound nurse later entered a progress note reflecting that the wound was worsening, had 100% slough/necrotic tissue, heavy drainage, and that the resident was in excruciating pain despite pre‑medication; this note was entered with a later date but described the earlier wound‑rounds encounter, and the nurse acknowledged she did not label it as a late entry to avoid it being flagged. The care plan for skin integrity was updated to include the wound doctor’s recommendation for hospital admission for operative debridement and possible leg amputation. The Medical Director stated that the wound doctor informed him of serious concern about the resident’s non‑healing venous ulcer, significant vascular compromise, and the need for hospitalization and evaluation by a vascular surgeon. The Medical Director reported that he gave a verbal order to the wound nurse for a vascular surgery consult and expected it to be carried out by the following day, but he did not send the resident to the hospital at that time because he did not feel it was urgent and had not reviewed the wound doctor’s notes or the documented deterioration of the wound. The order for the vascular consult was not entered into the medical record until five days after the verbal order, and the DON confirmed that only two attempts were made to obtain consent from the responsible party for the vascular consult during that period. The Medical Director also acknowledged that he did not assess the resident’s right leg ulcer after the wound doctor’s recommendation and could not recall the last time he personally assessed the wound, stating he had not gone out of his way to observe it because the facility had a wound team. Subsequently, the resident experienced a change in condition, with documentation by the wound nurse of low blood pressure (79/42), elevated respirations (30), slightly elevated temperature (99.6°F), non‑responsiveness compared to baseline, refusal of medications, refusal of breakfast, no fluid intake, facial grimacing with moaning, and refusal of pain medication. The resident was later sent to the hospital, where records showed presentation to the ED with confusion, increased heart rate, and low blood pressure due to septic shock related to cellulitis of the right lower extremity. Hospital findings included markedly elevated WBC, elevated lactic acid, CT evidence of a large soft tissue defect with fluid collection extending to the lateral ankle and forefoot muscles, and positive blood cultures for multiple bacteria. The resident was admitted to the ICU, later placed on comfort measures only, and died with causes listed as cardio‑pulmonary arrest, septic shock, and necrotizing fasciitis. Facility documents describing the Medical Director’s duties included coordinating medical care, participating in patient care review and infection control, being responsible for reviewing and evaluating patient care services, and making skin and high‑risk patient rounds, which contrasted with the Medical Director’s statements that he had not reviewed the wound documentation or assessed the wound after the wound doctor’s urgent recommendation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident receiving palliative care and scheduled morphine for pain had a lapse in the renewal process when a 30-day morphine order expired and the next order was not signed in time for pharmacy dispensing. The resident missed four doses over four days, with no refusals documented, and staff interviews showed the physician, Medical Director, DON, and LPNs all recognized that the order should have been renewed before it ran out.
Failure to Escalate Resident Change in Condition When Attending Physician Did Not Respond: A resident with HTN, type 2 DM, and impaired cognition developed tachycardia and then a fever with chills. The attending physician was notified but did not respond, and staff did not notify the Medical Director or any other physician after the lack of response, despite facility policy requiring escalation when the attending physician is unavailable or does not respond.
A resident with chronic pain and respiratory failure received a 10-fold overdose of Morphine after an NP changed the concentration but did not communicate the discontinued order or new dose directly to facility nursing staff. The MAR did not reflect the order change, the narcotic book showed the incorrect dose was given, and the overdose was not promptly reported or assessed before the resident was later sent to the hospital.
Failure to Ensure Timely Physician Oversight of Wound Care: A resident with Parkinson’s disease and high pressure-injury risk developed heel wounds that were not promptly assessed by the MD. The record showed missing physician documentation, incomplete or absent wound care orders, and worsening heel wounds with drainage and infection, including a culture with heavy growth of pseudomonas aeruginosa.
A resident with severe cognitive impairment and multiple psychiatric and GI diagnoses had significant unplanned weight loss, dropping 10.04% in 90 days and 12.64% in 180 days. She was observed sleeping through the day and refusing meals, and the record showed ongoing poor intake, supplement refusal, and weight fluctuations, but no documentation was provided showing that the physician was notified of the significant weight loss.
Failure to provide physician reassessment after a significant change in condition: a resident with a large, foul-smelling scalp lesion was found to have maggots in the wound. Staff notified the MD, who gave wound care instructions by phone, but did not come to assess the resident or document a reassessment before the resident’s outpatient surgery visit.
Missed Morphine Doses Due to Unrenewed Physician Order
Penalty
Summary
The facility failed to ensure that a resident’s medical care was supervised by a physician and that orders for immediate care and needs were maintained throughout the resident’s stay. The deficiency involved one resident who was admitted with Alzheimer’s disease, a stage 4 sacral pressure ulcer, and a closed fracture of the left femur, and who was receiving palliative care and scheduled opioid medication for pain management. The resident’s records showed ongoing physician orders for morphine sulfate oral solution, ordered in 30-day intervals for bedtime pain control. A morphine order that ended was re-ordered for another 30 days, but the prescription was not signed by the physician, so the pharmacy could not dispense it. As a result, the resident did not receive morphine for four days, with four doses missed, and there were no refusals documented in the record. The medication was later re-ordered after the resident’s family complained about the missed doses. Interviews showed that staff and providers were aware of the lapse in the renewal process. The physician stated nursing should have notified the physician when the order expired, and the Medical Director stated the lapses should not have happened and that nurses needed to call the physician when medication was running out. The DON stated nurses should initiate re-ordering early enough to avoid delays in obtaining the physician signature, and the pharmacist stated there was no explanation from the pharmacy side for why the order was not re-ordered until after expiration.
Failure to Escalate Resident Change in Condition When Attending Physician Did Not Respond
Penalty
Summary
The facility failed to ensure a physician or the Medical Director promptly provided medical care to a resident when the attending physician did not respond to a change in condition. The resident was admitted with diagnoses including left shoulder osteoarthritis, HTN, and type 2 DM, and had moderately impaired cognition with substantial/maximal assistance needed for several activities of daily living and partial/moderate assistance needed for others. On 7/4/2026, the resident developed tachycardia around 9:40 AM and later chills with a fever of 102.8 F around 12 PM. The SBAR form documented that the attending physician was notified for both changes but did not respond. The record did not show that the Medical Director or any other physician was notified after the attending physician failed to respond. During interviews, LVN 1 and RN 2 stated no other physician was notified, and RN 3 stated licensed nursing staff should notify the Medical Director immediately if there was no response from the attending physician. The DON stated the facility should notify the attending physician of any change in condition or notify the Medical Director promptly within one hour if there was no response.
Failure to Communicate Morphine Order Change and Overdose
Penalty
Summary
The facility failed to ensure that a resident’s medical care was supervised by a physician when a Morphine Sulfate order was changed without the new order being communicated directly to facility nursing staff and without the prior order being discontinued in the resident’s record. The resident had been admitted with diagnoses including acute and chronic respiratory failure and chronic pain disorder. A physician’s order for Morphine Sulfate 10 mg/5 mL, 2.5 mL by mouth every six hours as needed for moderate to severe pain was in place, and an E-Rx request later reflected a new Morphine Sulfate concentrate 100 mg/5 mL order for 0.25 mL every six hours as needed for pain. The July 2026 MAR did not show the earlier Morphine order discontinued or the new concentrated order transcribed. The narcotic administration book showed that 2.5 mL of Morphine Sulfate 100 mg/5 mL was administered, resulting in a 50 mg dose, which was 10 times the prescribed dose in the active physician’s order. The Optum NP who changed the prescription stated she did not notify the facility or communicate that she had discontinued the previous order and sent the new prescription, and she only communicated with the Optum RN. The Optum RN stated she was told the resident needed a refill and later discussed the order change with the NP, but did not contact the facility after that discussion. The resident was later evaluated by an Optum NP who was not informed of the overdose and entered new orders for repeat labs and vital signs every shift for three days, but the record did not show those orders were transcribed. When the overdose was finally reported to the Optum RN, she contacted the NP, who then gave orders to assess the resident, obtain vital signs, administer Narcan, and transfer the resident to the hospital because Narcan was not available in the facility. Staff interviews confirmed the provider changes were not communicated directly to facility nursing staff and that the overdose was not promptly assessed or reported to the provider.
Failure to Ensure Timely Physician Oversight of Wound Care
Penalty
Summary
The facility failed to ensure that a physician supervised care in a timely manner for one resident with significant wound care needs. The resident was admitted and later readmitted with diagnoses including muscle weakness, muscle wasting and atrophy, and Parkinson’s disease. The care plan identified the resident as high risk for pressure injuries due to decreased mobility, incontinence, decreased nutrition, and decline in overall medical condition. On arrival to the facility, a deep tissue injury was observed on the left heel, but the physician progress note the next day did not include evidence that the physician assessed or evaluated the heel wound or skin, and no measurements were obtained at that time. The record also showed ongoing wound care problems involving the resident’s heels. The MDS later indicated one unstageable deep tissue injury present on admission/reentry and stated the resident was not at risk for pressure ulcers. Physician orders from one period failed to include skin prep to bilateral heels, and later orders failed to include treatment for a right heel stage 3 pressure ulcer and then failed to include ordered wound care treatments such as cleansing with normal saline, applying xeroform, and covering with a dry clean dressing. A subsequent wound assessment documented a worsening right heel wound with increasing size, drainage, signs and symptoms of infection, and a wound culture later showed heavy growth of pseudomonas aeruginosa. The physician progress notes reviewed during this period did not show evidence of assessment or oversight of the resident’s wound care and treatment, and the ADON confirmed the facility failed to ensure timely physician supervision.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The provider failed to notify the physician of one resident who had unplanned significant weight loss. The resident had severe cognitive impairment with a BIMS score of 0 and diagnoses including mild neurocognitive disorder with behavioral disturbances, psychotic disorder, unspecified disorder of adult personality and behavior, unspecified intellectual disabilities, depression, non-infective gastroenteritis and colitis, and gastric ulcer without hemorrhage or perforation. Her weight decreased from 134.5 lbs on 4/12/26 to 121 lbs on 7/12/26, a 10.04% loss in 90 days, and from 138.5 lbs on 1/12/26 to 121 lbs on 7/12/26, a 12.64% loss in 180 days. The resident was observed asleep in bed during the day and was reported by CNA to have refused breakfast and lunch. She was later observed waking up but still lying in bed in the dark, and RN J later documented that the resident refused lunch again when awakened for medications. The record also showed repeated weight fluctuations and ongoing nutritional concerns, including refusal of supplements and picky eating discussed at a care conference. The DON stated that nursing staff would notify a physician if there was a 4 lb difference in weight, but no documentation was produced showing that the physician was notified about the resident's significant weight loss.
Failure to Provide Physician Reassessment After Maggot-Infested Scalp Wound
Penalty
Summary
The facility failed to ensure physician supervision and ongoing clinical oversight after being notified of a significant change in condition for one resident with a large scalp lesion. During observation, the resident had multiple black-colored lesions on the scalp, including a large central lesion about the size of a tennis ball that was partially covered with brown material and had yellowish, foul-smelling drainage. Staff reported that the resident was admitted with the lesion, that it intermittently drained, and that on 6/12/26 a staff member found maggots in the wound. After the maggot infestation was reported, a staff member assessed the resident and called the physician, who instructed staff to clean the area with soap and water, apply petroleum jelly, and cover the wound. The resident received a shower and the lesion was dressed per orders, but the physician did not come to the facility to assess the resident after notification. The physician later stated he did not evaluate or reassess the resident because an outpatient general surgery appointment was already scheduled. Record review showed no physician progress note documenting reassessment of the resident’s condition between the report of maggots and the outpatient surgical evaluation.
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