F0711

D

Failure to Obtain Physician Order for Temporary Secured Unit Placement

Weslaco, Texas Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain a written, signed, and dated physician order for a resident’s placement in a secured unit, as required by facility policy. Record review showed that a female resident with diagnoses including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension, and a severely impaired BIMS score of 4, had no physician order dated 03/11/26 for placement in the secured unit on her Order Summary Report. The resident’s admission record reflected an original admission date of 12/06/22 and a readmission date of 08/01/25. The facility’s Secured Unit Admission Criteria, dated 3/2026, specified that a physician order for placement would be obtained for secured unit placement.

Interviews confirmed that the resident was moved to the secured unit without a physician order. LVN B, the usual nurse for the secured unit, stated the resident was placed there the prior week for closer monitoring after an episode of shortness of breath and that the DON handled the placement; LVN B was unsure whether an order was required for a Wander Guard. LVN D reported that the resident was in her regular room on one day and in the secured unit the next morning, and that she was told in report the resident had shortness of breath overnight and was placed in the unit for closer observation, then later directed by the DON to return the resident to her room. The DON stated the resident was placed in the secured unit around 11:00 p.m. and returned to her room the following morning, acknowledged there was no physician order for the placement despite policy requiring one, and stated she did not know why she had not obtained the order. Review of the facility’s Wandering and Elopements Policy showed no criteria or implementation guidance for the use of a Wander Guard.