Failure to Monitor Resident and Implement Ordered Clear Liquid Diet After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to monitor and evaluate a resident after a documented change in condition and to implement physician-ordered interventions. Resident #2, who had COPD, stage 3 chronic kidney disease, Alzheimer’s disease, GERD, and unspecified abdominal pain, was moderately cognitively impaired but did not exhibit behaviors or reject care. On 02/12/2026 at 10:40 A.M., the resident complained of abdominal pain and had chocolate-colored emesis. The physician was notified and ordered monitoring and a clear liquid diet for two days, as documented in the progress note. Later that day at 6:53 P.M., a progress note indicated there was no further emesis noted during that shift. After the 6:53 P.M. note on 02/12/2026, there were no further progress notes or documented monitoring of the resident until 02/14/2026 at 12:30 P.M., when the resident again complained of chest pain and abdominal pain and was sent to the emergency department for further evaluation. No physician orders for monitoring or a clear liquid diet were entered into the medical record, despite the earlier documented physician instructions. The DON confirmed that orders should have been entered for monitoring and a clear liquid diet and verified the absence of progress notes documenting monitoring during this period. Facility policy on charting and documentation required that all services provided and any changes in the resident’s condition be documented in the medical record, which did not occur in this case.
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.