Failure to Assess and Notify Provider for Changes in Condition Leading to Delayed Treatment
Summary
The deficiency involves the facility’s failure to complete comprehensive nursing assessments and to identify and notify providers of significant changes in condition for two residents, resulting in delayed treatment, worsening symptoms, and hospitalization. One resident with CHF and COPD had standing orders for daily weights with specific parameters to notify the heart failure clinic for weight gains over 2 lbs in one day or 5 lbs in one week, and an order to apply O2 at 2 L/min if SpO2 fell below 90%. Over the course of a week, this resident’s weight increased by 8.1 lbs, and oxygen saturations were documented as low as 85% and 74% on room air on separate days, yet there was no documentation that the facility provider or heart failure clinic were notified as ordered. On another night, the resident’s SpO2 dropped to 84% on room air with tachycardia and elevated BP, and the nurse applied 3 L/min O2, documented the resident as DNR and on palliative care, and notified palliative care and the family, but did not complete a focused cardiac or respiratory assessment or notify the facility provider at the time of the change in condition. Subsequently, the DON initiated the facility’s sepsis protocol, which generated orders for labs and a chest x‑ray without a direct provider order, and these tests revealed a pleural effusion. The facility faxed lab and x‑ray results to the provider with a note indicating they were sent at the daughter’s request, and the provider initially responded that there were no new orders and asked if there was a special concern, indicating the provider had not been informed of the resident’s respiratory symptoms or the reason for the testing. Only later did the nurse fax additional information describing the low overnight SaO2, diaphoresis, lethargy, and the DON’s request for diagnostics, after which the provider ordered IM Lasix and monitoring of oxygen levels with instructions to notify if SpO2 dropped below 90%. Despite this, oxygen saturation was not reassessed again until the following morning, and there was no documentation of any comprehensive or focused respiratory or cardiac assessments from symptom onset through the arrival of EMS, nor any documentation of the resident’s condition, the timing, or rationale for transfer to the hospital. The second resident had diagnoses including adult failure to thrive, severe protein‑calorie malnutrition, and pressure injuries to the sacrum and coccyx, with care plans addressing dehydration risk and impaired skin integrity. A wound assessment documented an unstageable sacral pressure injury that was deteriorating, with heavy exudate, strong odor after cleansing, significant slough, tunneling and undermining, maceration, erythema, warm periwound, and saturated dressings, and a stage 4 coccygeal ulcer with moderate exudate and maceration. A provider communication requested a wound culture due to foul odor and copious drainage, and an order was obtained for culture and sensitivity. The culture, collected the next day, produced preliminary results over several days showing many gram‑negative rods, many gram‑positive rods, moderate gram‑negative cocci, and moderate WBCs, but the facility did not initiate its sepsis protocol order set, and the DON reported that the provider did not review preliminary culture results and only reviewed the final result, which was printed after the resident’s transfer to the hospital. For this resident, there was no documentation that the facility provider assessed the resident after the wound deterioration was identified, and no additional labs or diagnostics were ordered to rule out systemic infection despite documentation of foul odor, non‑healing, deterioration, and copious exudate. There was no documented risk‑versus‑benefit assessment regarding empiric antibiotics, even though preliminary culture data and prophylactic Bactrim use were present. A dietary note identified declining intake associated with oral thrush, but the record contained no documentation of interventions to promote fluid intake. A skin check later documented that baseline skin findings of warm, dry skin with normal color and turgor were “not met,” indicating a change in baseline and potential dehydration, yet there was no documentation of a comprehensive assessment or physician notification of this change. The resident was ultimately transferred to the ED at the daughter/POA’s request for further evaluation of possible wound‑related pain, with nursing documentation stating that vital signs were within normal limits and no acute changes were noted, while EMS and ED records later described hypotension, low O2 saturation, dry mucous membranes, skin tenting, toxic appearance, malodorous sacral/coccygeal ulcer, and concern for sepsis secondary to soft tissue infection. The facility’s own policies on change in status and notification of change require nurses to recognize and assess changes from baseline, obtain vital signs, review the record, observe overall condition and function, explore complaints, and promptly notify the practitioner and resident representative of significant changes or the need to significantly alter treatment, with accurate and timely documentation. The cited cases show that, despite these policies, the facility did not consistently perform comprehensive assessments, did not timely notify the attending practitioner of significant changes in condition, did not fully communicate the clinical context and symptoms when sending diagnostic results, and did not document assessments and decision‑making around changes in status and transfers. These failures led to delays in treatment, worsening of symptoms, and hospitalization for both residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Care Plan for Protective Sleeve: A resident with severe cognitive impairment, Alzheimer’s disease, dementia, and PVD had a care plan directing staff to keep protective sleeves on the left elbow at all times due to skin tear risk. During repeated dining room observations, the resident was not wearing the sleeve. A NA said she did not apply it because the resident would remove it and chew on it, and an RN said he was unaware the sleeve was not being worn.
Failure to follow wound care orders and dressing documentation requirements was cited for multiple residents. A resident had a skin tear dressed without a physician order, another resident had a knee dressing with no date or initials, and a third resident had a dated dressing and pain patch that did not reflect the ordered treatment schedule. The DON and wound care RN acknowledged that dressings and treatments should be completed as ordered and that dressings are expected to be dated and initialed.
Failure to Follow Ordered Treatments and Weight Monitoring: The facility did not ensure ordered care was carried out for several residents. One resident with Parkinson’s disease and anxiety sustained a skin tear to the hand during an agitated episode, but there was no physician order for the wound treatment that was provided. Two residents had ordered weekly weights that were not obtained as scheduled, and the records did not explain why. Another resident with HTN, depression, and DM had body blisters, but the wound company’s recommendation for skin prep was not entered as an order, and there was no documented evidence that the practitioner was contacted about the missed recommendation.
Failure to Follow Insulin Orders: Two residents with diabetes received insulin contrary to physician orders. One resident was given insulin aspart at times when blood glucose was below the ordered hold parameter, and a second resident received scheduled insulin without documented meal intake despite orders to hold if blood sugar was low or if less than 50% of the meal was eaten. The DON confirmed the medication administration did not follow the orders.
Failure to follow bowel management protocol: three residents had extended periods without a BM and no documented nursing interventions despite the facility’s protocol requiring specific measures after 2, 3, 4, and 5 days without a BM. The residents had significant diagnoses including schizophrenia, Parkinson’s disease, stroke, TBI, and Alzheimer’s disease, and the RNC confirmed the missing BM-related interventions in the chart.
A resident with dementia, severe cognitive impairment, limited ROM in both LEs, and dependence on staff for wheelchair locomotion was observed sitting in her wheelchair with her feet hovering above the footrests. CNAs confirmed her feet did not reach the footrests, and an administrative nurse stated the footrest needed to be adjusted to better fit and support her feet.
Failure to Follow Care Plan for Protective Sleeve
Penalty
Summary
The facility failed to ensure a sleeve protector was provided in accordance with the comprehensive care plan for a resident with severe cognitive impairment, Alzheimer’s disease, dementia, and peripheral vascular disease. The resident’s admission MDS identified the resident as needing partial/moderate assistance with upper body dressing and footwear and as being at risk for pressure ulcer/injury without existing pressure ulcers. The Pressure Ulcer/Injury CAA identified the resident as at risk for pressure ulcers and in need of a pressure relieving device for the bed and chair. The resident’s care plan, revised 7/28/26, identified a skin tear/potential for skin tear of the left anterior shin and left posterior calf related to falling and hitting self on the wheelchair, and directed staff to keep protective sleeves on the left elbow at all times. During multiple observations in the dining room, the resident was seated in a tilt-in-space wheelchair and was not wearing the protective sleeve to the left elbow. A NA stated she had been assigned to the resident all week and did not put the sleeve on because the resident would take it off and chew on it. An RN stated he was unaware the resident was not wearing the sleeve but said the resident should wear it if it was care planned. The DON stated the sleeve protector should be assessed and removed from the care plan if inappropriate, but staff were expected to follow the care plan to ensure the resident received the needed care.
Failure to Follow Wound Care Orders and Dressing Documentation
Penalty
Summary
The facility failed to ensure physician orders and facility policy were followed for wound care for 3 of 10 residents reviewed for wounds. Resident #28 was observed with a gauze dressing to the right wrist dated 08/06/2026, and the nursing note documented that a CNA noticed a new skin tear to the right wrist that was bleeding, was assessed by the nurse, cleaned, and dressed. However, review of the physician orders showed no wound care order for the right wrist. The wound care RN stated the resident did not have any wounds to her knowledge and explained that when a resident gets a skin tear, the nurse should cleanse it, recover the skin, dress it, notify the physician and family, and enter new orders. The DON stated the resident did not have orders for wound care to the right wrist and that the LPN should have notified the provider and obtained orders. Resident #21 was observed with an island dressing on the right knee that had no date or initials. The DON stated dressings are expected to be dated, and the wound care RN stated it is her practice to date and initial every dressing change, with weekend and PRN dressing changes done by the nurse on the cart. The TAR directed daily cleansing and application of a long island dressing to the right knee surgical site, and the facility policy for clean/dry dressings required tape/labels with date and initials. Resident #113 was observed with a dressing dated 8/6 and a white pain patch on the left arm dated 8/6/2026. The physician order required cleansing the left arm skin tear and applying xeroform, honey gel, and border gauze every day shift, and another order directed Aspercreme Lidocaine Patch 4% to the left shoulder in the morning and night and to the left hip with removal at bedtime. The wound care RN stated she was not familiar with the resident's skin tear dressing orders and that wound care should be done as ordered, while the DON stated dressings and treatments should be done as ordered and a check mark in the treatment record means completed.
Failure to Follow Ordered Treatments and Weight Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with orders and professional standards for four residents. Facility policy stated that weights were to be obtained routinely to monitor nutritional health, including weekly for the first four weeks after admission or readmission and more often if risk was identified or as ordered. For one resident with diagnoses including high blood pressure, Parkinson’s disease, and anxiety, a nursing note documented that the resident sustained a skin tear to the right hand during an episode of agitation and attempted physical aggression toward staff while being assisted out of bed. The wound nurse confirmed there was no physician order for treatment of the right hand skin tear, although steri-strips had been applied and the wound nurse stated steri-strips are the preferred treatment for skin tears. For two residents, physician orders required weekly weights, but the clinical record did not show that the ordered weights were obtained as directed. One resident had weights not obtained on two scheduled dates, and the record lacked additional documentation explaining why the weights could not be obtained. Another resident had one missed weekly weight, and the record also lacked additional documentation explaining why the weight was not obtained. The DON confirmed that the facility failed to make certain these residents were provided appropriate treatment and care. For another resident with diagnoses including hypertension, depression, and diabetes, the record showed the resident was admitted with marks and blisters on the body and no treatment was ordered. A contracted wound company later recommended skin prep to the blisters, but physician orders did not include skin prep. A wound nurse stated there was no order for skin prep and confirmed the facility did not follow the wound company’s recommendations. An RN stated the recommendations were not followed, but the facility had no documented evidence of speaking with the practitioner about treatment for the blisters or the reason the recommendations were not followed.
Failure to Follow Insulin Orders
Penalty
Summary
The facility failed to follow physician orders for two residents receiving insulin. One resident was cognitively intact, required maximum assistance with daily care needs, had diabetes, and was ordered to receive 6 units of insulin aspart at 8:00 a.m. with instructions to hold the medication if blood sugar was less than 110 mg/dL. Review of the MAR showed the resident received the insulin on multiple occasions when blood sugar readings were below that threshold, including readings of 92, 106, 105, 104, 94, and 75 mg/dL. The DON confirmed that the insulin had been administered on those dates and should have been held per the physician's order. A second resident was cognitively impaired, dependent on staff for daily care needs, and had insulin-dependent diabetes. The physician ordered 6 units/mL of insulin aspart twice daily with lunch and supper, with instructions to hold the dose if blood sugar was less than 150 mg/dL or if the resident ate less than 50 percent of the meal. The MAR showed no documented meal intake for several lunch and dinner meals on specified dates, yet the insulin was still administered. The DON confirmed that staff should have obtained the resident's meal intake before giving the insulin on those occasions.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its Bowel Management - Clinical Protocol for residents who did not have a bowel movement within the required time frame. The protocol dated April 2026 directed staff to assess, monitor, and manage bowel and bladder function according to individualized needs and physician/provider orders, with specific interventions beginning on Day 2, Day 3, Day 4, and Day 5 without a BM. For Resident #31, the record documented no BM from 7/27/26 at 2146 to 7/31/26 at 2130, with no documented nursing interventions during that period. Resident #31 had diagnoses including schizophrenia and alcohol abuse. Resident #4’s record documented no BM from 7/9/26 to 7/12/26 with no documented nursing interventions related to the lack of BM during that time. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #56’s record documented no BM from 7/21/26 to 7/28/26 and again from 7/29/26 to 8/2/26, with no documented nursing interventions during those periods. Resident #56 had diagnoses including stroke, traumatic brain injury, and Alzheimer’s disease. On 8/5/26, the RNC stated that Residents #4, #31, and #56 had no documented BM-related interventions for July and the first part of August 2026 and should have.
Wheelchair Footrest Not Adjusted for Resident With Limited LE ROM
Penalty
Summary
The facility failed to ensure appropriate wheelchair positioning for R11. R11 had a diagnosis of dementia, severe cognitive impairment on MDS assessments, limited ROM in both lower extremities, and was dependent on staff for locomotion in her wheelchair. Her care plan, revised 07/02/2026, instructed staff that she was dependent on staff for locomotion in her wheelchair. During observations on 08/03/2026 and 08/04/2026, R11 was seen sitting in her wheelchair at the dining room table with her feet hovering several inches above the wheelchair footrest. CNA M confirmed on 08/04/2026 that R11's feet did not reach the footrests, and CNA N stated the footrest needed to be adjusted to fit R11 better. On 08/05/2026, Administrative Nurse D also stated the footrest needed to be adjusted to better fit the resident and support her feet. The facility policy for Use of Assistive Devices stated that assistive device use would be based on the resident's needs, as indicated.
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