Failure to Act on Elevated Ammonia Level Resulting in Hospitalization
Summary
Facility staff failed to ensure that a resident’s abnormal laboratory result was appropriately evaluated and addressed by the practitioner. The resident had diagnoses including pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A progress note indicated that a cancer center appointment was cancelled and that the NP’s order for labs, including an ammonia level, should be followed. The resident’s ammonia level, drawn the following day, was 76 (reference range 9–35) and marked as high. The result was circled, annotated “NNO” (no new orders), and noted to have no previous ammonia level for comparison, and was signed by PA #1. There were no new treatment orders, no monitoring orders, and no corresponding progress note documenting assessment or clinical reasoning in the medical record related to this abnormal result. Subsequently, the resident experienced a change in mental status and abdominal pain. A progress note documented that the resident was sent to the ED for further evaluation after the resident’s family insisted on transfer. In the ED, the resident was found to have an ammonia level of 180 (reference range 9–35) and was diagnosed with hepatic encephalopathy. The resident was treated with lactulose and remained hospitalized for six days before discharge. The attending physician/Medical Director later stated that the resident had an elevated ammonia level that PA #1 had missed and acknowledged that the family was not happy with the situation. During interview, PA #1 confirmed that she had reviewed the elevated ammonia level and had not written any orders. She stated that because the resident did not have a history of hepatic encephalopathy and nursing staff had not reported a change in mental status, she decided not to treat the resident and did not write monitoring orders, believing such monitoring to be part of routine nursing care. She also reported that she had intended to recheck the ammonia level in a couple of days but failed to enter the order into the medical record. This failure to order treatment or monitoring, and the omission of the planned repeat ammonia level, occurred despite the clearly abnormal lab value and contributed to the resident’s subsequent hospitalization for hepatic encephalopathy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Physician Progress Notes for Required Visits: The DON confirmed that multiple residents’ charts lacked required physician visit progress notes. Records for residents with conditions such as dementia, DM, HTN, CHF, COPD, schizophrenia, Parkinson’s disease, dysphagia, and other chronic diagnoses showed long gaps between physician notes or no note during the initial post-admission period, despite policy requiring timely physician visits and documented progress notes at each required visit.
A resident with type 1 DM and a recent toe amputation had hospital discharge instructions that included considering sliding scale insulin and splitting long-acting insulin into BID dosing, but the attending physician did not document an independent review of those recommendations. The resident later developed a severe change in condition and was rehospitalized with acute encephalopathy likely metabolic in the setting of DKA and stress hyperglycemia, requiring an insulin drip, ICU care, and intubation before discharge to hospice.
A facility failed to ensure psychiatric assessment and services after a resident voiced suicidal ideation during PT eval and after another resident experienced a substantiated abuse incident and said they did not feel safe. Records showed no psych assessment after either event, despite existing behavioral health needs, psychotropic meds, and prior psych follow-up history.
A resident admitted with acute respiratory failure, asthma, pulmonary embolism, obesity, and DVT had an H&P that was not completed within the required 72 hours after admission. The DON reviewed the record and stated the attending physician should have completed the H&P on time, but the document did not show timely completion. The facility policy required physician visits to be timely and consistent with applicable state and federal requirements.
A physician failed to sign a resident’s admission orders in a timely manner. The resident was admitted after a right knee fracture, right knee replacement, and aftercare following surgery, and the orders were received on admission but were not acknowledged by the MD until weeks later. The DON, VPO, and RDCS confirmed the delay, and the MD stated he usually saw new admissions within 48 hours and had been signing orders manually when at the facility.
A resident with diabetes, arthritis, atrial fibrillation, and morbid obesity had physician orders on a 60-day review schedule, but the facility could not show when the orders were last signed in the paper record or EMR. The DNS and Corporate RN said orders should be signed every 30 or 60 days, but they could not provide documentation of timely physician/APRN review, signatures, or progress notes showing the orders were renewed on the required schedule.
Missing Physician Progress Notes for Required Visits
Penalty
Summary
The facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each required visit. Review of the facility policy stated that the attending physician must visit residents at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter, with a physician visit considered timely if it occurs no later than 10 days after the required date. The report also noted that physician progress notes were expected at each required visit. Clinical record review showed missing physician progress notes for 22 of 26 residents reviewed. Several residents had long gaps between documented physician visits, including residents with diagnoses such as dementia, diabetes, hypertension, atrial fibrillation, COPD, schizophrenia, seizure disorder, Parkinson’s disease, paraplegia, quadriplegia, and other chronic conditions. Examples included residents whose records showed a physician note in late 2025 and then no additional note until March 2026, with gaps ranging from 95 days to 179 days. One resident admitted in March 2026 had no evidence of a physician progress note completed at least once every 30 days during the first 90 days after admission. The report also identified residents whose records lacked required physician notes during the initial post-admission period or at required intervals thereafter. One resident admitted in January 2026 had a physician note on March 6, 2026 and again on April 14, 2026, but no note within the first 30 days after admission. Another resident admitted in December 2025 lacked evidence of physician progress notes within the first 30 days, at 60 days, and after the March 6, 2026 visit. During an interview on May 29, 2026, the DON confirmed that the listed residents’ records lacked the required physician visit progress notes and stated that physician progress notes should be completed at every required visit.
Physician Did Not Review Hospital Diabetes Discharge Recommendations
Penalty
Summary
The facility failed to ensure the attending physician conducted an independent, thorough review of a hospital discharge summary for Resident 161, who was admitted with type 1 diabetes mellitus and a recent right third toe amputation due to gangrene. The hospital discharge medication reconciliation listed Insulin Glargine 50 units subcutaneously daily and included free-text notes to consider sliding scale insulin during rehab and to consider splitting the long-acting insulin into twice-daily dosing. The medical record did not contain documented evidence that these discharge recommendations were reviewed and addressed by the attending physician. On [DATE], the attending physician stated they expected admitting nurses to communicate the hospital’s insulin sliding scale recommendations and said they would have agreed to follow the hospital recommendations for sliding scale insulin and to divide the resident’s long-acting insulin into two administrations. The physician also stated they believed the facility protocol was to perform blood glucose checks at least three times a day for residents admitted with diabetes. Later, Resident 161 had a change in condition with bradycardia, cold hands, oxygen saturation of 82% on room air, deep rapid respirations, inability to speak due to catching breath, and lethargy, and was sent to the hospital. The hospital discharge summary from that admission stated the resident had acute encephalopathy likely metabolic in the setting of DKA and stress hyperglycemia, was started on an insulin drip and DKA protocol, moved to the ICU, intubated due to altered mentation and respiratory failure, and was discharged to hospice care.
Failure to Assess Residents After Suicidal Statement and Abuse Incident
Penalty
Summary
The facility failed to ensure that residents who made serious behavioral health statements or experienced a traumatic incident were assessed and provided necessary psychiatric services. The facility assessment stated that it was dedicated to effectively managing medical conditions and medication-related issues that may contribute to psychiatric symptoms and behavioral challenges, and the facility policy on Psychiatry and Psychology Services stated that residents would be provided, arranged for, or referred to psychiatric and psychological services sufficient to meet identified needs. However, the record showed no psychiatric assessment for one resident after a suicidal statement was documented by Physical Therapist #1 during evaluation, and no psychiatric assessment for another resident after an abuse incident in which the resident reported being handled roughly and stated they did not feel safe. One resident was readmitted with diagnoses including unspecified fracture of the right femur, peripheral vascular disease, and anxiety disorder, and had a BIMS score of 15 indicating no cognitive impairment. On 11/20/2025, Physical Therapist #1 documented that the resident was voicing suicidal ideation during evaluation and notified the Social Worker and Director of Rehabilitation. The chart contained no further documentation regarding the suicidal ideation, and review of the record revealed that no staff member completed a psychiatric assessment before or after the statement. The resident’s chart included psychotropic medication orders such as alprazolam and escitalopram, and care plans addressed behavior changes, psychosocial well-being, and anxiety, but there was no care plan for depression or suicidal ideation. The other resident had diagnoses including anoxic brain damage, hemiplegia following cerebrovascular disease affecting the right dominant side, and contractures of both hands, and was dependent on staff for all activities of daily living. After an incident on 01/25/2026, the internal investigation documented that a CNA was witnessed handling the resident roughly and yelling during care, and the resident reported being treated roughly and having ice cold water used during hygiene care. The investigation substantiated abuse, and the resident later stated they had been nervous, jumped when staff entered the room, and did not feel safe in the facility. Review of the chart revealed no psychiatric assessment after the incident, despite prior psychiatric follow-up history in the record and the resident’s report of fear and lack of safety.
Delayed Completion of Resident H&P
Penalty
Summary
The facility failed to ensure that Resident 2’s History and Physical (H&P) was completed within 72 hours of admission, as required by facility policy. Resident 2 was admitted on 3/2/2026 with diagnoses including acute respiratory failure, asthma, pulmonary embolism, obesity, and DVT in both legs. A review of the MDS dated 3/8/2026 showed the resident was cognitively intact. During a concurrent interview and record review on 5/20/2026, the DON reviewed Resident 2’s H&P dated 3/16/2026 and stated it should have been completed by the attending physician within 72 hours after admission; the H&P did not indicate it was completed on time. The facility policy titled Physician Visits, dated 1/20/2026, stated the attending physician will visit residents in a timely manner consistent with applicable state and federal requirements.
Delayed Physician Signature on Admission Orders
Penalty
Summary
The facility failed to ensure the physician signed off on resident orders in a timely manner for one resident out of three reviewed for timely physician orders. Resident #47 was admitted on 01/30/26 with diagnoses including right knee fracture, right knee replacement, and aftercare following surgery. The medical record showed physician orders were received on the admission date, but Medical Director #408 did not acknowledge the orders until 04/08/26. During interview, MD #408 stated he usually saw new admission residents within 48 hours and had been at the facility at least weekly, but said he had signed orders manually when present and did not currently have electronic access. The DON and VPO stated MD #408 had electronic access and that IT was working to put access on his cell phone; the DON also stated she had been working with MD #408 to get the orders signed in the electronic record. The RDCS confirmed the admission date and that the orders were not acknowledged until 04/08/26, and confirmed the physician orders should have been signed more timely.
Physician Orders Not Reviewed and Renewed on Required Schedule
Penalty
Summary
The facility failed to ensure that a resident’s physician orders were reviewed and renewed at least every 60 days. Resident #1 had diagnoses including diabetes, arthritis, atrial fibrillation, and morbid obesity. The quarterly MDS showed a BIMS score of 14 out of 15, indicating no cognitive impairment, and the care plan identified diabetes, risk for hyperglycemia and hypoglycemia, and pain risk, with interventions to administer medications as ordered and assess pain. Record review identified the resident was on a 60-day schedule for review and renewal of physician orders, but the facility could not identify when the physician orders were last signed by the physician or APRN in either the paper record or the EMR. During interview, the DNS and Corporate RN stated that resident physician orders should be signed every 30 days or every 60 days, and explained that some orders were signed on paper while others were electronic in the EMR. They also stated that long-term resident orders originating before the current EMR appeared in monthly reports without physician signatures and were marked as signed in wet ink on paper. The DNS and RN were unable to provide documentation showing that Resident #1’s orders had been reviewed and signed, or any physician/APRN progress notes showing the monthly orders were reviewed and renewed. After surveyor inquiry, Corporate RN #4 provided documentation showing the monthly orders were signed by MD #1 on 4/16/2026, but could not provide documentation that the orders had been signed every 60 days before that date. The facility did not provide a policy related to physician visit frequency or the frequency of review and signatures for paper or electronic orders.
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