Failure to Timely Assess and Escalate Care for Persistent Upper Extremity Pain and Swelling
Summary
The deficiency involves the facility’s failure to timely and adequately address a resident’s ongoing left upper extremity pain and swelling despite multiple reports and observable changes in condition. The resident was admitted with dementia, severe cognitive impairment (BIMS score of 6), muscle weakness, and chronic kidney disease. On 1/7/2026, nursing documented that the resident was yelling that her hand hurt, and an ARNP was notified, who ordered an X‑ray of the hand/wrist and PRN Tylenol. The X‑ray on 1/7/2026 showed no fracture, anatomic alignment, and no soft tissue swelling. The resident’s RR was informed that the X‑ray was clear. A change in condition report was completed that same day for hand pain, but no further documented nursing assessment of the left upper extremity followed after this initial workup. On 1/9/2026, a PTA performing a quarterly therapy screen noted that the resident complained of left wrist pain and resisted giving her hand when positioned on her side. The PTA reported these concerns to the unit nurse and documented them on a communication form, but the medical record contained no subsequent nursing assessment by an LPN in response to this report. Pain Management evaluated the resident starting 1/17/2026 for left wrist pain and swelling and ordered routine Tylenol and a topical gel. The Pain Management provider later stated he did not perform range of motion because the resident was in too much pain when her wrist was moved and that he relied on nursing to report further pain, which they did not. The ARNP saw the resident again on 2/3/2026 for a routine visit and acknowledged being aware of prior pain and discomfort in the left hand and wrist, but her progress note contained no documented range of motion or focused assessment of the left hand, wrist, or shoulder; she later stated she did not know why she failed to document her assessment. During this period, the resident’s RR observed progressive changes. After being told the initial X‑ray was clear, he visited about a week later and noticed swelling of the arm and an abnormal hanging position of the hand. When he lightly touched the arm above the wrist, the resident screamed in pain. He reported this to nursing and made multiple phone calls requesting to speak with the DON about the plan of care but did not receive a return call. Eventually, he went to the facility, located the DON, and showed her the resident’s arm; when the DON and physician touched the arm, the resident again screamed in pain. The RR insisted on hospital transfer, while the DON initially suggested trying other in‑house measures. A nursing note dated 2/10/2026 documented that the RR requested emergency room evaluation for left hand/wrist edema and pain and a provider change. The Medical Director examined the resident that day, noting left arm swelling and pain present for over four weeks, the resident’s refusal to allow range of motion, and the inability to fully examine the axilla. He agreed with the RR to send the resident to the emergency room for immediate imaging. At the hospital, the resident was found to have a left shoulder dislocation that could not be reduced, and the hospital physician documented that the shoulder appeared to have been dislocated for a long time. The facility’s change‑in‑condition policy required prompt notification and documentation of changes in condition, but the facility was unable to provide an assessment change‑in‑condition policy beyond the general notification policy, and the record lacked timely, thorough nursing assessments in response to repeated reports of pain and swelling. Additional staff interviews corroborated that the resident repeatedly voiced pain without corresponding documented follow‑up assessments. A CNA recalled hearing the resident yelling in pain while passing meal trays and reported this to the nurse, after which she only heard that an X‑ray had been done. An LPN stated that about a month before the hospital transfer, a CNA reported the resident’s hand pain; she observed some swelling, notified the ARNP, and obtained the initial X‑ray and PRN Tylenol, but she did not describe any further systematic reassessment after the negative X‑ray. The DON stated that her expectation was that when another discipline reported a change in condition, the nurse should notify the physician and family and complete a change‑in‑condition note, with follow‑up documentation that the physician and family were made aware. She also stated that 2/10/2026 was the first time she personally assessed the resident and observed that the resident was in pain and unable to move her arm. The combination of repeated complaints of pain, observed swelling and abnormal arm positioning, lack of documented follow‑up assessments after therapy and Pain Management reports, and delayed escalation to hospital evaluation led to the discovery of a longstanding left shoulder dislocation. The facility’s own documentation and staff statements show that, despite multiple indicators of a persistent and worsening problem with the resident’s left upper extremity, there was no timely, comprehensive reassessment or escalation of diagnostic evaluation beyond the initial negative hand/wrist X‑ray and symptomatic treatment with Tylenol and topical gel. The ARNP’s lack of documented assessment of the left upper extremity during the 2/3/2026 visit, the absence of nursing assessments following therapy’s 1/9/2026 report of continued wrist pain, and the failure of the DON to respond to multiple calls from the RR about the resident’s condition all contributed to the delay in identifying the true source of the resident’s pain. Ultimately, the resident’s RR’s insistence on hospital transfer prompted the emergency room evaluation that revealed the left shoulder dislocation, which the hospital physician believed had been present for at least a month.
Penalty
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An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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