Failure to Implement Hospital Discharge Orders for Weight-Bearing and Isolation Status
Penalty
Summary
The facility failed to ensure that physician orders from a transferring hospital regarding weight-bearing status and isolation needs were accurately transferred and implemented for one admitted resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status requiring immunosuppressive medication, and difficulty in walking. Hospital discharge orders dated 10/09/25 included a non–weight-bearing order for the right lower extremity and a requirement for a private room due to immunocompromised status related to the kidney transplant. Review of the resident’s physician orders at the facility showed that the non–weight-bearing status for the right lower leg and the isolation precautions related to immunosuppressive medication were not present. In an interview, the DON stated that the resident should have had these physician orders in place per the hospital discharge instructions and that her expectation was that all hospital admission orders be reviewed and clarified before the resident’s arrival. The DON confirmed that the admission nurse did not review and clarify these admission orders, and as a result, they were not implemented.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.