F0609

D

Failure to Report Alleged Neglect After Delay in Following MD Transfer Order

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

Penalty

No penalty information released

Summary

The facility failed to report an allegation of neglect to the New Jersey Department of Health (NJDOH) after a resident with multiple cardiac conditions experienced a significant change in condition and a physician’s order to send the resident to the hospital was not promptly carried out. The resident had diagnoses including systolic congestive heart failure, atrial fibrillation, and hypertension, and a comprehensive MDS showed moderate cognitive impairment with a BIMS score of 11/15. On the morning in question, nursing documentation reflected that the resident had loose stools with very foul-smelling, dark fluid, and vital signs showed a blood pressure of 73/47 mm Hg, which is below the normal adult range.

According to a late-entry physician progress note, the physician gave a verbal order at 9:33 AM to the Assistant Director of Nursing (ADON #2) to send the resident to the emergency room due to low blood pressure. A late-entry provider note by ADON #2 stated that after being notified by a float nurse, ADON #2 assessed the resident, found them responsive without labored breathing, repositioned them, attempted to contact the physician, notified the DON for assessment, and documented that the physician gave an order to send the resident out at 9:59 AM, after which 911 was activated and the resident was transferred while still responsive. However, in an interview, the physician stated that when ADON #2 called around 9:30 AM, she instructed that 911 be called and the resident be sent to the ER, and when she arrived at the facility at 10:00 AM, she assumed the resident had already left.

The physician further reported that at about 10:10 AM she was informed by an LPN that the resident was still in the facility with a further decreased blood pressure of 64/34 mm Hg, and that staff told her they were waiting for her to come in. The physician stated that ADON #2 told her they were waiting for labs to be drawn before calling 911, which the physician indicated was not appropriate for the resident’s condition, and only then was 911 called. The DON reported that facility leadership was not made aware of the delay in sending the resident to the hospital until after the resident expired at the hospital, and that ADON #2 had not informed her despite documenting in a late-entry note that the DON had been notified. The Licensed Nursing Home Administrator acknowledged that the event should have been reported to NJDOH, and review of facility policies showed that allegations or suspicions of neglect and resident safety events were required to be promptly reported to regulatory authorities, which did not occur in this case.