F0684

G

Failure to Follow Medication, Weight Monitoring, and Wound Care Orders for Three Residents

Elizabethtown, Pennsylvania Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for medications, diagnostic monitoring, and wound care for three residents. For the first resident, who was cognitively intact, dependent for ADLs, and diagnosed with chronic diastolic CHF, the physician ordered torsemide 120 mg PO BID and later ordered weights three times weekly with specific parameters to notify the provider and the resident’s daughter of significant weight changes or refusals. After a hospitalization for CHF and discharge with instructions to continue torsemide 120 mg BID, the facility’s MAR showed an order for only 20 mg BID. A subsequent cardiology consult documented that the resident “should be on 120 mg of torsemide but since [they have] only been getting 20 BID, increase to 60 mg BID” and requested daily weights. The TAR documented only two weights over several days, and there were gaps in weight documentation despite orders for more frequent monitoring.

Further documentation for the first resident showed ongoing weight fluctuations and edema consistent with fluid retention. Dietary notes identified significant weight changes and referenced increased torsemide per progress notes, while nursing notes described refusal of an outside IV diuresis appointment, abnormal BMP and magnesium results, and provider orders to encourage fluids and increase torsemide to 80 mg BID with BP monitoring. Cardiology later ordered torsemide 80 mg BID, daily pre-breakfast weights, and instructions to call for specified weight gains or worsening symptoms. Subsequent weights showed increases, and nursing notes documented weeping edema of the bilateral lower extremities, a 5‑pound weight gain, and 3+ pitting edema. The provider was notified and ordered BLE ultrasound and blood work, and the family arranged a cardiology appointment. The cardiology office later reported the resident was being sent to the ED for fluid volume overload, and hospital records confirmed admission for acute on chronic CHF. The surveyors concluded the facility failed to implement medication orders and failed to monitor the resident’s weight as ordered, resulting in increased CHF symptoms and actual harm.

For the second resident, a physician ordered oxycodone 5 mg PO every eight hours for three days. The MAR showed missed doses on three occasions, with only one progress note indicating a dose was held because the resident was hard to arouse with low SpO2; there was no documentation explaining the other missed doses. The record also lacked evidence that the physician was notified of the resident’s change in condition or of the missed oxycodone doses. Wound consult documentation for this resident described bilateral lower leg cellulitis with detailed treatment orders, including Betadine to the left leg and acetic acid with Xeroform and bordered dressing to the right leg, and later an order for hydrogel with foam dressings and compression wraps to both legs. However, the right leg wound care order was not present in the physician orders, the Betadine order for the left leg was not transcribed to the TAR, and the hydrogel treatment ordered on March 20 was not completed as ordered from March 20 until March 26 because it was not transcribed into the TAR. Nursing notes recorded that the resident was removing leg dressings but did not document what replacement treatments or dressings were applied. The DON confirmed the wound orders were not followed as ordered, and a corporate nurse reported EMR changes with order transcription contributed to the issue.

For the third resident, who had a history of a left lower leg wound with hematomas requiring incision and drainage, cellulitis, and lymphedema, a wound consult documented an unstageable left calf wound with tunneling and ordered NPWT (wound vac) at 125 mmHg continuous three times per week and as needed. A later nursing note indicated the wound vac was discontinued after a wound center appointment, and a new physician order directed cleansing the left lower leg with soap and water, applying Prisma and calcium alginate twice weekly, and applying Profore compression from toes to knees. Weekly skin assessments documented that the resident’s skin was not intact but did not include an assessment of the left calf wound on specified dates, and there was no documentation of weekly wound assessments on additional dates. The DON confirmed that the left calf wound was not assessed from December 31 until January 21. Overall, the surveyors determined the facility failed to ensure physician orders were followed and that ordered monitoring and treatments were completed for all three residents, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing Services.