F0726

D

Failure to Transcribe and Initiate Physician Orders for Respiratory Treatment

Rapid City, South Dakota Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure by nursing staff to ensure that physician orders for an antibiotic, medicated nebulizer treatment, and cough syrup were transcribed and initiated for a resident with respiratory symptoms. On 3/3/26, an RN reported that the resident was experiencing cough and congestion to a PA-C, who then evaluated the resident at the facility. The PA-C verbally told the RN and the DON that the resident should continue to be monitored but did not verbally communicate that new medications were being prescribed. The PA-C entered orders for an antibiotic, nebulizer treatment, and cough syrup into the HUCU messaging system and documented these orders in a progress note in the electronic medical record at 12:16 p.m. that day.

The RN who had received the verbal report from the PA-C did not log into the HUCU messaging system to check for new orders for the resident after being told to monitor him. As a result, the orders entered by the PA-C on 3/3/26 were not transcribed into the nursing home's computerized medical record system and were not initiated. The RN also did not inform the night shift of any new medications for the resident and reported that the resident had no additional acute needs during her shift. The HUCU messaging system did not provide alerts when new orders or messages were sent, and the only way to identify new orders was for nurses to manually log in and check, which did not occur in this case.

On 3/4/26, the resident left the facility with family for lunch and appeared to be at his baseline when observed by an LPN before departure. Upon returning around 1:00 p.m., the resident was later found by staff to be weak, non-responsive, sluggish, and non-verbal. The LPN caring for the resident attempted to contact his emergency contacts and, after speaking with his son, arranged for the resident to be sent to the ER for evaluation at approximately 2:15 p.m. While preparing for the transfer, the LPN logged into the HUCU messaging system to notify the primary care provider and discovered the PA-C’s orders from the previous day, which had not been transcribed or initiated. The resident was admitted to the hospital with diagnoses including sepsis related to pneumonia, elevated troponin, acute kidney injury, acute encephalopathy, and metabolic acidosis. Review of the resident’s records confirmed that no physician orders had been transcribed or initiated on 3/3/26 and that the facility’s policies required nurses to correctly and safely receive and transcribe physician orders, including those received electronically.