Failure to Monitor and Respond to Acute Change in Condition Leading to Septic Shock
Summary
The deficiency involves the facility’s failure to timely and accurately assess a resident with multiple chronic conditions and to respond appropriately to an acute change in condition. The resident had diagnoses including GERD, hyperlipidemia, hypothyroidism, chronic gout, fatty liver, intellectual disabilities, OSA, COPD, fibromyalgia, insomnia, anxiety, diabetes mellitus, and panic disorder. Her care plan identified a potential for altered respiratory function related to COPD and OSA, with goals to prevent respiratory distress and infection, and interventions such as auscultating lung sounds, elevating the head of bed, encouraging fluids, coughing and deep breathing, and obtaining vital signs and pulse oximetry as ordered and as needed. Despite these identified risks and interventions, the facility did not ensure comprehensive assessment and monitoring when the resident’s condition changed. In the days leading up to the hospitalization, the resident and CNAs reported symptoms consistent with infection and decline. The resident stated she had a UTI for approximately two weeks and that she complained for four to five days of being unable to void and feeling unwell, but felt no one listened. CNAs reported the resident complained of itching, burning, frequent urge to urinate, not being cleaned or changed enough, not eating, and not getting out of bed, which was a change from her usual routine of getting up around the same time daily and walking to the bathroom. Staff reported these concerns to nurses and were told the resident would be given medications and monitored, but there was no evidence in the record that these complaints triggered a comprehensive nursing assessment or timely provider notification specific to these urinary and systemic symptoms. Provider orders were obtained on multiple occasions without corresponding documentation of assessment or rationale. On one date, the NP ordered Mucinex and percussive ventilation, and on another date ordered Diflucan and nystatin powder, both without any nursing or NP progress notes explaining why the orders were given or documenting a comprehensive assessment. Later, the NP ordered a chest x-ray, CBC, BMP, COVID test, Doxycycline, scheduled DuoNebs, and BID vital signs with specific parameters for notifying the provider if temperature, blood pressure, pulse, respiratory rate, or SpO2 were outside defined ranges. The chest x-ray subsequently showed diffuse bilateral lower lung opacities suggestive of pulmonary edema, atelectasis, and/or pneumonia, but there was no evidence the provider was notified of these abnormal results. The NP also documented the resident had respiratory congestion, increased temperature, and decreased oxygen saturation, and ordered monitoring of vital signs with instructions to alert the provider if changes were noted, but the facility did not document the required ongoing monitoring or follow-up. On the morning of the acute event, the respiratory therapist and an RN documented that the resident was febrile with a temperature of 102.1°F, tachycardic with a heart rate of 138, respiratory rate of 24, and SpO2 of 83% on room air, with bilateral rhonchi. The resident was placed on 3 L/min oxygen via nasal cannula, and the NP ordered Augmentin in addition to existing Doxycycline, Tylenol, laboratory tests, and vital signs every four hours for 24 hours. There was no documented rationale for adding a second antibiotic or a medical diagnosis to support the treatment, and no documentation that the abnormal vital signs were otherwise addressed beyond ordering Tylenol. After an 8:12 A.M. note showing post-nebulizer SpO2 of 91%, heart rate 121, respiratory rate 24, and persistent bilateral rhonchi, there was no documentation of the ordered q4h vital signs, no evidence of increased monitoring, and no documentation of interventions such as encouraging fluids, deep breathing, or upright positioning. More than ten hours later, an LPN starting the evening shift found the resident in a markedly worsened state. The LPN reported that the off-going nurse described the resident as sick but fine, yet upon walking rounds the LPN observed the resident with eyes rolled back, unresponsive, visibly lethargic, with irregular respirations and increased difficulty breathing. Vital signs at that time showed hypotension with a blood pressure of 55/31 mm Hg, temperature 102.3°F, heart rate 94, SpO2 90% on 3 L/min oxygen, and a mean arterial pressure of 39. EMS was called and the resident was transferred to the hospital. The facility’s own review concluded that nursing staff failed to follow the NP’s order for every four-hour vital sign monitoring, resulting in the resident’s decreasing blood pressure and declining condition not being recognized until the evening, and the surveyors determined that the facility failed to ensure the resident was comprehensively assessed and provided timely, necessary, and effective intervention in response to her change in condition. Hospital records documented that the resident was admitted with severe septic shock, acute cystitis, pneumonia, UTI, acute kidney injury, and acute hypoxic respiratory failure, requiring ICU-level care, vasopressor support, BiPAP, central venous catheter placement, and multiple IV antibiotics. The resident later reported that the emergency room physician told her it was almost too late and that she would have expired, and she described the experience as very traumatic. The facility census at the time was 52 residents, and this deficiency affected one resident reviewed for change in condition. The surveyors determined that the facility’s failure to timely and accurately assess the resident and respond to her acute change in condition resulted in Immediate Jeopardy and actual harm.
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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