F0600

J

Failure to Follow Physician Order for Immediate ER Transfer After Acute Hypotension

Dover, New Jersey Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to carry out a physician’s order to immediately transfer a resident to the emergency room (ER) following a significant change in condition and hypotension. The resident had multiple diagnoses including systolic congestive heart failure, atrial fibrillation, and hypertension, and had a BIMS score of 11/15 indicating moderate cognitive impairment. On the morning in question, nursing staff documented that the resident had loose, foul-smelling, dark stools and was encouraged to increase oral hydration, with SpO2 at 95% on 2 L/min oxygen via nasal cannula. At 8:54 AM, the resident’s blood pressure was recorded as 73/47 mm Hg, which is below the normal range.

A physician telephone order was entered at 9:20 AM to send the resident to the ER for emergency transfer due to low blood pressure and change in condition. The physician later documented a late entry stating that at 9:33 AM she had given a verbal order to nursing (to the ADON) to send the resident to the ER due to low blood pressure. The physician reported that she instructed the ADON to call 911 and send the resident out immediately. However, the resident remained in the facility. Nursing notes documented that during morning rounds the resident appeared disoriented, with blood pressure 71/47 mm Hg, heart rate 64 bpm, temperature 97.7°F, respiratory rate 18, and SpO2 95% on 2 L/min oxygen. The LPN documented that the ADON was made aware, obtained orders for STAT labs, X-ray, and urinalysis, and was waiting for a response from the physician.

The physician stated that when she arrived at the facility at 10:00 AM for scheduled rounds, she believed the resident had already been transferred. At approximately 10:10 AM, an LPN informed her that the resident was still in the building and that the blood pressure had decreased further to 64/34 mm Hg, and that they had been told to wait until the physician arrived. The physician then reiterated that the resident needed to be sent to the ER immediately, and 911 was called. Nursing documentation later that day indicated that the resident was transported to the ER and was admitted with diagnoses including unspecified shock, anemia, and hyperkalemia, and that the resident expired at the hospital the same day. The facility’s records and interviews showed discrepancies between the ADON’s late-entry note and the order audit report, as well as conflicting statements about whether the DON had been notified, and the facility’s investigation documentation was limited and lacked specific resident identifiers and incident details.

Interviews with facility staff further described the sequence of events leading to the deficiency. The ADON was reported by the Assistant DON and nursing staff to have been notified of the resident’s low blood pressure and change in condition, to have ordered STAT labs and diagnostic tests, and to have indicated that they were waiting on the physician or on lab results before calling 911, despite the physician’s order for immediate transfer. The physician stated that waiting for labs was not appropriate for the resident’s condition. The DON reported that she was not made aware of the situation until after the resident expired and that a late-entry note by the ADON claiming DON notification was not accurate. The LNHA acknowledged that there appeared to have been a delay in sending the resident to the ER and provided an undated, generic investigation summary that did not include the resident’s name, date of incident, or attached statements. The surveyors concluded that the facility failed to implement its abuse, neglect, physician notification, and change in condition policies when staff did not promptly carry out the physician’s order for immediate ER transfer, resulting in a finding of neglect and an Immediate Jeopardy situation.