F0684

E

Failure to Follow Orders, Monitor Changes in Condition, and Implement Safety Devices

Stow, Ohio Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and goals, as well as failures in comprehensive monitoring after a change in condition. One hospice resident with severe cognitive impairment was lowered to the floor from bed during an early morning episode in which she believed her bed was on fire. Staff documented no pain, no change in range of motion, and no suspected injury immediately after the incident, and planned only to monitor for pain and bruising. Hospice was not notified of the incident at that time. Over the next several days, documentation showed increasing complaints of left hip and leg pain with pain scores up to eight and nine out of ten, bruising to the left buttock and knee, and repeated administration of PRN acetaminophen, which staff recorded as effective. The NP noted soreness and bruising, low suspicion of fracture, and initially ordered but then cancelled x‑rays after discussion with staff, based on the belief the resident had been lowered rather than fallen and had no uncontrolled pain. Hospice staff later assessed the resident, observed significant pain and favoring of the left leg, and requested imaging; x‑rays eventually revealed a probable subcapital fracture of the left femur, and subsequent hospital evaluation confirmed an acute impacted intracapsular subcapital femoral neck fracture requiring surgical fixation. The resident’s son and hospice nurse reported that the resident had complained of pain since the incident, that the facility delayed notifying the son of the event, and that hospice had to reiterate the need for imaging.

Another deficiency involved a resident with severe cognitive impairment and multiple cardiovascular diagnoses who had physician orders for three antihypertensive medications (Amlodipine, Hydrochlorothiazide, and Lisinopril) to be held if systolic blood pressure was less than 120. The MAR showed numerous blood pressure readings below the ordered threshold throughout the month, resulting in the medications being held on multiple occasions, including three consecutive days. There was no documentation that the physician or NP was notified of these repeated medication holds. Additionally, on one date when the systolic blood pressure remained below 120, all three medications were administered instead of being held, contrary to the physician’s parameters. The DON confirmed that the provider had not been notified of the repeated holds and that the medications should have been held on the date they were administered.

A further deficiency concerned a resident with diabetes, dementia, and a left dorsal foot wound who had a physician order for daily wound care with normal saline, Medihoney, calcium alginate, and appropriate dressings. The TAR for the month showed the treatment as completed daily; however, during observed wound care, the kerlex dressing on the resident’s foot was dated two days prior, indicating the dressing had not been changed as ordered. The LPN performing the dressing change confirmed the date and believed the dressing was to be done daily and as needed, revealing a discrepancy between documentation and actual practice.

Additional deficiencies involved failure to implement ordered perimeter mattresses for residents at risk for falls or needing defined bed boundaries. One resident with dementia, muscle weakness, and dependence for transfers had a physician order in place for an air perimeter mattress for several months. Observations showed a bag containing a perimeter mattress topper sitting on the resident’s chair rather than on the bed, and staff, including the LPN and DON, were initially unaware of what was in the bag or that it needed to be applied. The DON later confirmed that the perimeter mattress order had been in place since January and that the topper should have been on the bed. Another resident with dementia and cognitive deficits had a care plan intervention for a bari‑bed with perimeter mattress and a later physician order for a perimeter mattress to assist with bed boundaries. The DON stated she was unsure when this resident actually received the mattress and that the physician order was not entered until weeks after the care plan intervention was documented, indicating a delay in implementing the ordered safety device.