F0610

D

Failure to Investigate Delayed ER Transfer After Physician Order and Resident Death

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an unexpected resident death and to rule out neglect after a physician’s order for immediate transfer to the ER was not followed. A resident with systolic congestive heart failure, atrial fibrillation, and hypertension had a recent MDS showing a BIMS score of 11, indicating moderate cognitive impairment. On the morning in question, nursing documentation showed the resident had loose, foul-smelling dark stools and was encouraged to increase oral hydration, with SpO2 at 95% on 2 L O2 via nasal cannula. At 8:54 AM, the resident’s BP was documented at 73/47 mm Hg, well below normal. A physician progress note, entered later as a late entry, recorded that at 9:33 AM the physician gave a verbal order to nursing (to the ADON) to send the resident to the ER due to low BP.

Subsequent nursing notes documented that during morning rounds the resident was awake, responsive but disoriented, with BP 71/47, HR 64, temp 97.7°F, RR 18, and SpO2 95% on 2 L O2. Nursing staff notified the ADON, who ordered STAT labs, X‑ray, and urinalysis and indicated she would contact the physician. A provider progress note by the ADON, entered as a late entry, stated that she was initially unable to reach the physician, that the DON was immediately notified, and that the physician gave an order to send the resident out at 9:59 AM, after which 911 was activated. However, the facility’s order audit report showed a telephone order at 9:20 AM to send the resident to the ER for emergency transfer due to change in condition, contradicting the ADON’s late entry note about the timing and sequence of events. The physician later stated she had instructed the ADON around 9:30 AM to call 911 and send the resident to the ER and that she assumed the resident had already left when she arrived for rounds at 10:00 AM.

Interviews with staff revealed conflicting accounts and suggested a delay in carrying out the physician’s order to transfer the resident. The physician reported that at about 10:10 AM she was informed by an LPN that the resident was still in the facility with a BP of 64/34 mm Hg and that staff told her they were told to wait until she came in. The physician stated that the ADON told her they were waiting for labs to be drawn before calling 911, which the physician considered inappropriate for the resident’s condition. Nursing notes documented that when the physician arrived, the resident’s BP was 63/36, SpO2 could not be obtained, and the physician again ordered transfer to the ER, after which 911 was called and the resident was transported and later expired in the hospital that day. The DON stated she was not made aware of the situation until after the resident’s death, despite the ADON’s late entry note claiming the DON had been notified, and that the ADON resigned after writing the back‑dated note. The administrator provided an undated, untitled, one‑page “investigation” summary and conclusion with no resident name, incident date, or attached statements, which did not reflect the detailed events, conflicting timelines, or staff interviews described elsewhere in the record. This minimal document did not meet the facility’s own Abuse Investigation and Reporting and Reportable Events policies, which require prompt, thorough investigations, interviews, medical record review, and root cause analysis for serious events.

The facility’s policies required that all reports of suspected neglect and serious reportable events be promptly identified, thoroughly investigated, and documented, including interviews of involved staff and witnesses, review of the medical record and care plans, evaluation of contributing factors, and root cause analysis for serious events. The DON reported that corporate was made aware and conducted an investigation but that she herself was not interviewed. The administrator acknowledged there appeared to have been a delay in sending the resident to the ER and attributed the situation in part to interpersonal conflict between two ADONs. The only investigation document produced consisted of a brief, generic summary and conclusion describing hypotension with stable heart rate and oxygen saturation, ongoing monitoring, physician communication, and eventual transfer to the ER, without specific identification of the resident, the date, the sequence of orders and actions, or any analysis of the delay or conflicting documentation. As a result, the surveyors determined that the facility failed to thoroughly investigate the unexpected death and the apparent failure to promptly follow a physician’s order for emergency transfer, and therefore failed to rule out neglect as required by facility policy and regulation.