F0684

D

Failure to Follow Physician Orders and Assessment Protocols for Falls, Acute Changes, and Vascular Access

Norwalk, Connecticut Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and facility policies for documentation, assessment, and vascular access management. One resident with multiple orthopedic, neurologic, cardiac, respiratory, and psychiatric diagnoses, who was cognitively intact and on psychoactive medications, opioids, and an antipsychotic, experienced a slip while exiting an elevator after having previously sustained toe fractures from a fall. Staff did not classify the elevator event as a fall, did not report it to the nursing supervisor on the day it occurred, and did not complete a nursing assessment or documentation at that time. The Assistant Director of Nursing Services later learned of the event directly from the resident the following morning and documented the resident’s report of slipping and having pain in the same previously injured foot. Staff reported that they did not complete an Accident and Incident report because the resident described the event as a slip rather than a fall, and the then-Director of Nursing Services had advised that no report was necessary. This was inconsistent with the MDS definition of a fall and with facility policies requiring documentation of changes in condition, evaluation of falls, and reporting of accidents and incidents.

Another resident with dementia and a history of cerebral infarction had a documented care plan for altered cardiovascular status, including assessment of chest pain, shortness of breath, and cyanosis and reporting changes to the physician. On one occasion, this resident was found pale and unresponsive in a wheelchair, and the physician was notified with an order to send the resident to the emergency room. An LPN documented vital signs and notification of the physician and responsible party, and another LPN recalled checking the resident’s blood sugar and obtaining a minimal response to a sternal rub before transferring the resident to bed. The resident became more alert and was transferred to the hospital. However, there was no documented RN assessment in the clinical record prior to the transfer, no documentation of the exact time of the incident, no times for EMS arrival and departure, no description of the resident’s state of alertness at transfer, and no documentation of sending a face sheet or calling the hospital emergency room with report. This lack of RN assessment and incomplete documentation did not meet the facility’s Acute Condition Changes/RN Assessment Protocol, which required RN involvement and documentation when residents experienced acute changes in condition.

A third resident with sepsis had been discharged from the hospital with a midline catheter placed in the upper arm for IV antibiotic therapy. The hospital discharge summary and intra-agency report identified the device as a midline catheter, and an outside IV company’s documentation described placement of a 12 cm midline catheter in a vein in the inner left arm, with instructions for midline care per protocol. However, the admitting nurse obtained physician orders for a central line catheter rather than a midline, including orders for central line observation, dressing changes, and flushing with normal saline followed by heparin. The facility did not use heparin in IVs, and the prepopulated heparin orders should have been removed. There were no appropriate midline-specific orders entered on the MAR/TAR for dressing changes, flushing, or routine site assessments, and there was no documentation that dressing changes or flushes had been completed since admission. The midline site was observed with a clear dressing and a manufacturer label stating "MIDLINE," but the clinical record lacked consistent documentation of care per the facility’s midline catheter policies, which required specific physician orders and detailed documentation of flushing, dressing changes, and site assessments.

A fourth resident with type 2 diabetes, chronic kidney disease, ESRD on hemodialysis, psychiatric diagnoses, and mild cognitive impairment had a physician’s order allowing leave of absence only with a responsible party and medications. This resident was cognitively intact and psychiatrically stable at the time. On one occasion, the resident told staff they were going to the lobby but instead left the facility alone via a ride-share without notifying staff or signing out on LOA, contrary to the active physician order requiring accompaniment by a responsible party. Staff discovered the resident was no longer in the lobby and then determined the resident had gone to a local hospital to see a nephrologist. At the time of this event, the physician’s order had not yet been updated to allow independent LOA, and the resident’s departure without a responsible party was inconsistent with the existing order. This failure to follow the physician’s LOA order contributed to the overall deficiency in ensuring care and services were provided in accordance with physician directives and facility policies.