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
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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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