Failure to Assess and Intervene for Respiratory Distress and Hemoptysis
Summary
The deficiency involves the facility’s failure to provide timely and thorough assessment and intervention for residents experiencing significant respiratory changes and possible bleeding while on anticoagulant therapy. For Resident #16, who had chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, atrial fibrillation, and sleep‑related hypoventilation, the care plan directed staff to monitor for signs and symptoms of respiratory distress and to report changes to the provider as needed. Physician orders included PRN albuterol nebulizer, PRN albuterol‑budesonide inhaler, and oxygen at 2 L/min via nasal cannula to maintain oxygen saturation above 92%, with documentation of oxygen saturation, pulse, respirations, and lung sounds pre‑ and post‑administration when PRN treatments were used. The April MAR/TAR showed no documentation that PRN respiratory medications were administered, and the electronic record for 4/15/26 contained only a weekly skin assessment and an infection assessment, with no documented respiratory assessment despite multiple indications of respiratory compromise. On 4/15/26, Resident #16’s oxygen saturation readings included 96% on room air at 4:29 AM and 90% on BiPAP at 8:11 AM, with later readings of 93% on BiPAP. Staff G, the RN caring for the resident that morning, reported that when therapy sat the resident on the side of the bed, she could not get enough air and her oxygen saturation was 68%, prompting staff to put her back on BiPAP, after which the saturation reportedly increased to 94%. Staff G stated she completed an assessment, repeatedly checked oxygen saturation, and listened to lung sounds, but she did not document these assessments or the subsequent oxygen readings. She also stated she increased oxygen to 2.5 L when the saturation was 90%, but did not document the change or obtain a corresponding physician order, despite saying she notified the physician. The clinic nurse later stated she was not told about an oxygen saturation of 68% and that, had she known, the physician would likely have ordered ED evaluation. The DON acknowledged that Staff G noted a low oxygen level of 68% and applied BiPAP but did not document interventions or use of PRN albuterol as expected. Throughout the day, Resident #16 and her husband reported that she felt ill for several days, complained of fluid overload, shortness of breath, and difficulty breathing, and that she was gasping for air during therapy. The husband and resident both stated that staff did not appear concerned, did not perform assessments when she reported feeling ill, did not offer PRN breathing treatments, and did not increase oxygen. Staff D, a CNA, confirmed that during an attempted transfer with therapy, the resident said she could not breathe, took long deep breaths between words, seemed weak and tired, and insisted on lying back down; he recalled that her oxygen was low but did not remember the exact number. Despite these reports, there was no documented comprehensive respiratory assessment on 4/15/26. Later that evening, the resident called 911 herself, reporting someone nearby was having a stroke. EMS found her pale, cool, confused, and hallucinating, with oxygen saturation in the high 60s to low 70s and respirations of 36. EMS documented rales bilaterally, initiated CPAP with escalating PEEP due to persistent respiratory distress, and transported her to the ED, where she was diagnosed with possible pneumonia and CHF exacerbation. The primary care physician stated he was not informed of oxygen saturations in the 60s or 70s and that such values would have warranted notification and ED evaluation. For Resident #41, the report identifies another failure to follow care plan directives related to respiratory status and anticoagulant use. This resident had intact cognition, diagnoses including hypertension, pneumonia, COPD, and atrial fibrillation, and was receiving apixaban 5 mg twice daily. The care plan for altered respiratory status directed staff to monitor for and report signs and symptoms of respiratory distress, including hemoptysis, and the anticoagulant care plan directed staff to report blood‑tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle/joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and significant or sudden changes in vital signs. The report notes that this resident was reviewed in the context of coughing/spitting up blood while on an anticoagulant, indicating that staff did not complete appropriate assessment or intervention in response to hemoptysis as required by the care plan and physician orders. Specific details of the communication to the physician are referenced in a fax communication dated 3/30/26, but the excerpt provided ends before the content of that fax is fully described, leaving the documented deficiency focused on the failure to adequately assess and respond to the resident’s reported coughing/spitting up blood. Collectively, the findings show that for two of three residents reviewed, staff did not complete timely, comprehensive assessments or implement ordered or care‑planned interventions when residents exhibited low oxygen saturation or hemoptysis. For Resident #16, this included lack of documented respiratory assessments, failure to use or document PRN respiratory medications, failure to document oxygen adjustments and subsequent vital signs, and failure to communicate critical oxygen saturation values to the physician or clinic nurse. For Resident #41, this included failure to follow care plan directives to assess and report hemoptysis in the context of COPD and anticoagulant therapy. These actions and omissions occurred despite clear care plan instructions and physician orders directing staff to monitor for and respond to respiratory changes and bleeding‑related signs and symptoms.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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