Failure to Follow Diabetic Orders, Notify of Changes in Condition, and Complete Post-Fall Assessments
Summary
The deficiency involves multiple failures to implement diabetic care and follow physician orders, to notify providers and family of changes in condition, and to complete required post-fall assessments for several residents. One resident with long-standing type 1 diabetes was admitted after hospitalization for dehydration and hyperglycemia, with hospital discharge orders for Novolog insulin per sliding scale three times daily, insulin glargine 12 units every evening, and frequent blood glucose monitoring. These hospital orders, including the Novolog sliding scale and instructions to monitor blood glucose regularly, were not fully transcribed into the facility’s physician orders or MAR, and a baseline care plan addressing diabetes and the use of a continuous glucose monitor was not created. Blood glucose monitoring three times daily before meals was not consistently documented until several days after admission, and some blood glucose readings were missing. Staff obtained blood pressures on the arm where the continuous glucose monitor was located, despite the device manual indicating that pressure on the sensor can affect readings, and there was no order or care plan instruction to avoid that arm. For this same resident, nursing notes show that insulin glargine was held on the evening of admission due to vomiting and lack of food, without notifying the provider. The resident refused bolus tube feedings on subsequent days, and these refusals were not reported to a provider. Nursing documentation shows episodes of very high blood glucose readings, including “over high/over 400” on the continuous glucose monitor, with additional insulin doses given per immediate orders, but there were gaps in blood glucose checks, including a period where the continuous glucose monitor was not working and the resident refused finger-stick checks. Staff did not consistently notify the physician when the continuous glucose monitor failed or when the resident refused blood glucose checks. The physician later stated that hospital orders for Novolog sliding scale three times daily should have been continued, that staff should have reported the device malfunction and refusals, and confirmed that the lack of appropriate monitoring and insulin administration contributed to the resident’s rehospitalization for diabetic ketoacidosis, with an emergency room glucose level of 1194 mg/dL. Another resident with diabetes had orders for insulin glargine and short-acting insulin (insulin aspart/Novolog) but had numerous doses of both long-acting and short-acting insulin held over multiple months without documentation that the physician was notified. The MAR shows that long-acting insulin glargine was not administered on multiple evenings, and short-acting insulin aspart/Novolog scheduled three times daily was held many times even when blood glucose was greater than 110, despite there being no active order after readmission to hold the short-acting insulin for blood glucose less than 110. The physician later stated this was the first time he became aware that staff were holding long-acting insulin, that he does not order parameters to hold long-acting insulin, and that staff should report any time insulin is held outside ordered parameters. The DON confirmed there was no documentation of provider notification for the held insulin doses and that there was no active order to hold the short-acting insulin. The deficiency also includes failure to timely notify a physician and family of a change in condition following a fall, resulting in delayed treatment of a compression fracture. One resident with severe cognitive impairment experienced an unwitnessed fall and was found sitting on the bathroom floor. Initial assessment documented no injuries, and the resident was returned to the wheelchair. Over the next days, the resident developed increasing lower back pain, became tearful and crying, and required PRN pain medication. Nursing documentation shows that pain was rated as high as 8 on a 1–10 scale, and an LPN obtained orders for a lumbosacral x-ray and PRN ibuprofen. However, there is no documentation that the new onset and increased back pain following the fall was reported to a provider prior to the day the x-ray was ordered, and no documentation that the resident’s family was notified of the pain or the new orders until the day the x-ray results were received and the resident was transferred to the hospital. The family member reported being told only that the resident had fallen and then later that the resident was going to the hospital, without interim updates about pain or diagnostic testing. Post-fall assessment deficiencies were also identified. For the resident with the unwitnessed fall, neurological assessments were documented at multiple time points after the fall, but all entries contained the same set of vital signs recorded at the initial time, indicating that vital signs were not actually reassessed and documented as required. The RN acknowledged that neurological checks should be completed every 15 minutes for one hour, every 30 minutes for two hours, then every four hours for 24 hours with vital signs each time, and confirmed that all documented checks showed the same vital signs from the initial assessment. Another resident with diabetes, a history of subdural hematoma and subarachnoid hemorrhage, and current anticoagulant therapy (Eliquis) experienced a witnessed fall while attempting to self-transfer. There was no documentation that blood glucose was checked at the time of the fall or that neurological assessments were initiated, despite the resident’s diabetes and prior brain bleed. The LPN involved stated that blood glucose was not checked because the resident was alert and did not appear hypoglycemic, and that neurological assessments were not started because the fall was witnessed. The DON later stated that neurological assessments should be initiated for any unwitnessed falls, but the documentation shows that required neurological and blood glucose assessments were not completed as outlined in facility policies and care plans.
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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