F0684

G

Failure to Complete Skin Checks and Inadequate Response to Change in Condition

Carlisle, Pennsylvania Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete ordered and care-planned skin assessments for one resident and failure to provide timely, comprehensive assessment and response to a change in condition for another resident. For the first resident, who had multiple sclerosis, diabetes mellitus, dementia, and zoster encephalitis, the care plan included interventions to observe skin for abnormalities and report changes in skin integrity to the Nurse Practitioner, with these interventions initiated in 2019. The January 2026 Medication Administration Record documented that weekly skin checks were not completed on four separate dates, and there were no corresponding progress notes regarding these missed skin checks. A regional clinical support staff member confirmed that the weekly skin check should have been completed for this resident.

For the second resident, who had Alzheimer’s disease, thyroid cancer, and metastatic cancer of the liver, colon, and lymph nodes, the facility did not provide timely and comprehensive care and services after a documented change in condition. Laboratory results showed abnormal and worsening values for sodium, chloride, calculated osmolality, potassium, and calcium over several days, consistent with dehydration and electrolyte disturbances. The Nurse Practitioner documented lethargy and non-responsiveness to verbal stimuli and ordered IV D5W for hypernatremia/dehydration and a one-time dose of potassium chloride 40 mEq on two separate dates. The March Medication Administration Record did not show that the ordered potassium dose was administered, and the Director of Nursing’s later assertion that the potassium was placed on hold by the Nurse Practitioner was not supported by any documentation.

On the day of acute decline, nursing documentation noted lethargy, refusal of meals with minimal fluid intake, and later an acute visit by the physician who found the resident unresponsive and ordered transfer to the emergency room. An SBAR completed by the RN supervisor documented fever and unresponsiveness as the change in condition, with limited vital signs and no repeat vitals after the change in condition except for blood pressure. The SBAR omitted the abnormal laboratory results, new medications, and IV fluids, and indicated that respiratory and neurological assessments were not clinically applicable, despite the resident’s altered responsiveness. There was no nursing assessment documented of the resident’s condition after the change in status. EMS records indicated a delay in gaining access to the locked unit, absence of staff in the resident’s room on arrival, shallow breathing requiring immediate oxygen via non-rebreather, and difficulty obtaining report, code status, and medical history from staff. EMS documented that care was delayed due to waiting for access, that staff were initially on their phones and not answering the door, and that a nurse present knew only limited information about the resident’s condition and medications. Hospital records showed the resident required intubation and was admitted to the ICU with acute respiratory failure, failure to thrive, cardiac arrest, hypocalcemia, and hypokalemia, and the facility’s failures were cited as not assessing the resident after a change in condition, delaying the 911 call by approximately 54 minutes after the physician’s order to send the resident out, not remaining with the resident to monitor for further decline, not assessing respiratory status despite respiratory distress, and not providing EMS or the ED with timely and thorough report.

The cited regulatory violations included 28 Pa. code 201.14(a) Responsibility of licensee, 28 Pa code 201.18(b)(1) Management, and 28 Pa code 211.12(c)(d)(1)(3)(5) Nursing services. These citations were based on the failure to complete routine and weekly skin checks as ordered and care-planned for one resident, and the failure to provide timely, accurate, and comprehensive assessment, monitoring, documentation, and communication in response to another resident’s significant change in condition, including omission of critical clinical information on the SBAR and lack of appropriate respiratory assessment and presence of staff during EMS arrival and transfer.