Failure to Recognize and Report Resident’s Deteriorating Condition and Hypotension
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices when there was a clear change in condition. The resident was an adult male with Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a physician. On the day in question, a medication aide documented hypotensive blood pressure readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., but there was no corresponding change-in-condition assessment completed that day, and the low readings were not effectively communicated to the licensed nurses responsible for his care. Throughout that day and night, multiple staff observed and described significant deviations from the resident’s usual baseline without ensuring appropriate nursing assessment and provider notification. A CNA working the day shift reported that the resident, who normally liked to play on his computer, slept most of the day and did not eat breakfast or lunch except for one cup of vanilla pudding; he stated he told the floor nurse but could not recall who it was or what action was taken. Another CNA on the night shift stated the resident was “out of it,” barely spoke, slept most of the shift despite usually staying up late, had heavy breathing, and only nodded his head with eyes closed in response to questions; she reported communicating these concerns to the night nurse and checking on him several times. The medication aide on the 2:00 p.m. – 10:00 p.m. shift acknowledged that the resident’s blood pressure was low and that he held the resident’s blood pressure medication, but he could not clearly identify which nurse he informed or what the nurse’s response was. Licensed nurses on both shifts reported that they were not made aware of the resident’s low blood pressure readings or his refusal of meals. The day-shift LVN stated she received no notifications from CNAs or medication aides that the resident had low blood pressure or had not eaten, and she indicated she would have contacted the provider if she had known of a systolic reading of 86. The night-shift LVN stated she checked on the resident several times, received nods or brief verbal responses, and did not recognize a change in behavior; she also stated she was told by a CNA that the resident had not eaten breakfast or lunch but believed that CNA had already informed the day nurse. Neither LVN had knowledge of the documented hypotensive readings. The following morning, another LVN found the resident barely responsive, clammy, with an untouched breakfast tray, a blood pressure of 75/54, and unresponsiveness to a sternal rub, at which point EMS was called and the resident was sent to the hospital. Hospital staff and the primary medical doctor later described the resident as having been deteriorating for hours, with findings including blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and he required multiple rounds of CPR. The facility’s own policy titled “Change in Resident Condition” required that when there was a significant change in a resident’s physical, mental, or psychosocial status, the medical provider should be contacted. The DON stated that when the medication aide identified low blood pressure, he should have notified the nurse immediately, and that CNAs and medication aides were expected to provide verbal updates to nurses, who in turn were responsible for notifying the provider, completing documentation, and ensuring oversight. In this case, despite documented hypotension, decreased intake, increased sleepiness, and altered responsiveness over many hours, there was a breakdown in communication and follow-through: the low blood pressure readings were not effectively reported to the LVNs, no change-in-condition assessment was completed on the day of the abnormal readings, and the provider was not contacted about the resident’s change in condition until the following morning when he was found unresponsive and required emergency transfer. The primary medical doctor later stated that the resident was found unresponsive to a hard sternal rub with low blood pressure and vomit around his mouth, and that he appeared to have been deteriorating for hours. A hospital registered nurse reported that the resident was admitted due to unresponsiveness, required three rounds of CPR because his heart stopped, and imaging and cultures showed an infarct and blood infection. A hospital nurse practitioner stated that the resident was positive for a blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and that his unresponsiveness was caused by multiple factors. The resident’s family member reported that his mind had been very sharp despite prior stroke-related mobility issues and expressed gratitude that the LVN who found him unresponsive returned to check on him, stating that this likely saved his life. These findings collectively demonstrate that staff did not act in accordance with the resident’s care plan and facility policy regarding timely recognition, assessment, and reporting of a significant change in condition.
Removal Plan
- Removed medication aide #1 from his assignment pending completion of in-service training on Medication Administration, Reporting of Abnormal Vital Signs to the charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action related to failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process, including: evaluation/assessment; documenting findings (vital signs and Change in Condition assessment/progress note); reporting changes to the medical provider; notifying the resident representative; documenting all actions in the EHR; reviewing medication aide vital sign forms for abnormalities with reassessment/interventions; reporting changes to the oncoming nurse during handoff.
- Required that no nursing staff work their next assigned shift until all required in-service training is completed.
- Educated all certified medication aides on medication administration (five rights) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process, including when to use it, completing it in the EHR and/or on paper, communicating it to the nurse, and turning the form in to the charge nurse for nurse follow-up.
- Required the nurse to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the Director of Nursing when a change in condition is identified and Stop and Watch is completed, including that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse’s station and specified secure storage locations for staff use.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for State surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication/orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all nursing staff on leave/PRN are in-serviced prior to working their shift and that administrative nursing staff provide in-service/education prior to staff working their next assigned shift.
- Implemented ongoing monitoring/verification using a Change in Condition audit tool with audits to ensure compliance.
- Implemented/maintained medication aide vital sign monitoring logs and required medication aides to handwrite vital signs on the designated form and submit to the charge nurse for review.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F684 and the plan of removal.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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