F0684

E

Failure to Monitor, Implement Orders, and Notify Providers/Families for Changes in Condition

Chrisman, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and report changes in condition and to follow physician and NP orders for multiple residents, despite policies requiring such actions. For one resident with CHF and respiratory issues, the NP assessed increased cough, congestion, wheezing, and fatigue and ordered a chest x-ray, CBC, CMP, use of spirometer, PRN nebulizer treatments, supplemental O2 if needed, and ongoing monitoring of respiratory status. The record shows PRN nebulizer treatments and oxygen use over several days, but there is no documentation of vital signs or respiratory assessments during that period and no evidence that the ordered chest x-ray and labs were completed. The resident was later sent to the hospital for shortness of breath and cough and was admitted with sepsis secondary to pneumonia and acute hypoxemic respiratory failure. The NP and MDS coordinator confirmed that no assessments or vital signs were documented between the NP visit and the hospitalization, and that the x-ray company only contacted the facility after the resident had already been transferred.

Another resident with severe cognitive impairment and multiple cardiac and vascular diagnoses had a documented pulse increase to 106 after a period of pulses in the 60s–80s, with no subsequent blood pressures, pulses, assessments, or notifications to family or providers. Nursing notes later document that the resident was transferred to the ER for lack of response to stimuli, cold extremities, and gurgling, with EMS finding the resident unresponsive, flaccid, cold, mottled, and in respiratory distress with very low oxygen saturation and hypotension; the resident died at the hospital. The day-shift RN did not recall any changes or follow-up on the elevated pulse and stated that any reassessment or reporting would have been documented, which it was not. A CNA reported that the resident had been nonverbal, had purple, cold legs, and had not swallowed medications the evening before, and that these changes were reported to the RN, but there is no documentation of reassessment, monitoring, or provider/family notification in the record.

A third resident with atrial fibrillation, COPD, hypertension, and diabetes had care plan interventions to monitor diuretic side effects and report pertinent lab findings. The NP ordered a CBC and CMP, and later the physician ordered spironolactone with a repeat BMP in one week, but there is no documentation that these lab orders were entered or completed. The resident had a recent elevated WBC and cellulitis with ongoing antibiotics, and the MAR shows the resident refused morning medications on one date with no documented reason or follow-up. The resident later died in the facility, and there is no documentation that the provider or family were notified of the medication refusal or the resident’s statements about wanting to die, which CNAs reported had been communicated to nurses.

A fourth resident with CKD stage 4 and recent hospitalization for dehydration and acute kidney injury was receiving spironolactone, Bumex, and Eliquis. Lab results showed elevated BUN and creatinine with low eGFR, and the NP documented hyperkalemia likely due to CKD and dehydration, with IV fluids given and a CMP ordered. Subsequent CBC/CMP results showed continued renal impairment, and new orders were written for CBC and CMP over a defined period, but there is no documentation that these orders were implemented or that results were obtained. Nursing notes show the resident was treated with antibiotics and pain medications for broken teeth, bleeding gums, and infection, but there is no documentation that these dental problems and need for a dentist were reported to the resident’s guardian. The guardian later stated they were unaware of the dental issues or need for dental care until the day of a hospice referral, indicating that significant changes and conditions were not communicated as required by facility policy.