Failure to Recognize and Respond to Sepsis-Related Changes in Condition
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and exercised appropriate competencies to recognize and respond to significant changes in condition, including signs and symptoms consistent with sepsis, for two residents. For Resident #1, who had been admitted after surgical repair of a hip fracture and was consistently documented as alert and oriented with no cognitive impairment, the clinical record showed a rapid decline beginning overnight. Late in the evening, his blood pressure was within normal limits and no neurological concerns were documented. By early the next morning, his blood pressure had dropped significantly, and the weekend on-call provider was contacted about hypotension, resulting in orders to hold certain medications, test for blood in stool, and perform hourly blood pressure checks. Subsequently, Resident #1’s condition further deteriorated. At 7:30 a.m., he was documented as unresponsive to verbal stimuli with low blood pressure and decreased oxygen saturation on room air, and his unresponsive neurological status persisted throughout the day. The primary care physician (PCP) was notified and ordered IV fluids at 100 ml/hr, followed by additional IV fluids later in the morning as hypotension, tachycardia, and worsening oxygenation continued despite escalating oxygen support. Vital signs remained unstable, with blood pressures in the 70s–80s systolic and low diastolic readings, heart rate of 132, and fluctuating oxygen saturations requiring up to 8 LPM of oxygen. The PCP eventually ordered transfer to the hospital around midday, and EMS documentation listed sepsis with hypotension as the primary impression. The resident’s death certificate identified sepsis as the cause of death. In an interview, the LPN assigned to Resident #1 during the morning shift stated she did not remember the resident or the events but acknowledged, after reviewing her notes, that she had contacted the PCP and followed his orders for IV fluids and monitoring. She reported that she did not question the provider’s orders, believed it was not her role to judge their appropriateness, and stated she could not send a resident to the ER without an order. When presented with a scenario involving low blood pressure, loss of consciousness, and declining respiratory status, she did not identify sepsis as a likely cause and reiterated that as a nurse she could only follow physician orders. She also stated she did not know who the facility’s medical director was. The DON stated that sepsis recognition and immediate action are expected nursing standards in the facility and that sepsis has been a long-standing focus of nursing education. For Resident #2, the facility also failed to demonstrate competent recognition and timely response to a significant change in condition consistent with sepsis. The resident was documented as alert, responsive, talking, and answering questions with staff in the evening. Shortly thereafter, a CNA reported a change in condition, and an LPN assessed the resident, finding hypotension with a blood pressure of 78/46 and signs of acute distress, including lethargy, respiratory congestion, labored breathing, and intermittent gasping. The LPN identified the condition as possible sepsis but did not immediately contact the on-call provider. Nearly an hour elapsed between the assessment and the call to the provider, who then ordered transfer to the hospital. The LPN later stated she believed she was required to speak with a provider before sending a resident out and could not explain the delay between recognizing the change in condition and contacting the provider. The DON again stated that nurses in the facility are expected to recognize early signs and symptoms of sepsis and take immediate action, and that nurses have autonomy to use their judgment to send residents to the hospital even without a provider’s order. The facility’s President of Operations stated that the facility did not have a policy regarding competent nursing staff. The DON reported that newly hired nurses receive some training on identifying sepsis at hire and that all staff receive annual refresher training on sepsis, but also acknowledged that it would be very hard to say that either resident was transferred to the hospital in a timely manner. These findings, based on staff interviews, physician interviews, facility document review, and clinical record review, support the conclusion that the facility failed to provide competent nursing staff capable of recognizing and appropriately responding to significant changes in condition, including signs and symptoms consistent with sepsis, for two residents in the survey sample.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
LPNs Assigned Wound Care Without Competency Assessment: Several LPNs were assigned wound care duties for residents even though the facility had not assessed their competencies or provided wound care training. The LPNs stated they had limited or no wound care education or certifications, and some said they did not feel comfortable performing wound care. Leadership confirmed wound care responsibilities had been shifted to floor nurses and that no competency evaluations or training had been provided.
Licensed nursing staff did not have competencies completed on hire, and the facility did not ensure staff had the skills needed to carry out resident care and monitor changes in condition. One resident’s positive urine culture was not reported to the NP for days, and another resident did not receive ordered BID BG checks; abnormal lab results and a recommendation for IV fluids were documented, but no follow-up was found in the record. The facility assessment listed competency areas such as change in condition and BG testing, and the Regional RN confirmed new-hire competencies were not being completed.
Lack of Mechanical Lift Competency for Direct Care Staff: A resident sustained a witnessed fall from a Hoyer lift during a transfer by two staff members and was later noted to have pain in the RUE and bilateral hips, with a head strike also documented. Review of staff files showed one LNA had no documented mechanical lift training or competency, and a Support Aide who sometimes helped with Hoyer transfers reported she had not received facility training on transfers or lift use.
An LVN failed to follow a resident's oxycodone order by administering the medication when documented pain scores were below the ordered parameter. The LVN could not explain medication parameters or what to do when a resident was outside the parameter, and the DON stated that medication parameters are used for resident safety and that not following them can cause complications, medication toxicity, and ineffective treatment.
Missing Staff Orientation, Competency, and Performance Documentation: The facility failed to ensure required orientation, annual competency skill assessments, and annual performance evaluations were completed for multiple staff members. Record review found an LPN with an expired CPR card, an RN with no CPR card or orientation checklist after rehire, and several CNAs with missing skills checklists, orientation forms, or annual performance reviews; HR staff said records were not kept up and were not filed properly.
Failure to In-Service CNA on Merry Walker Safety for High-Fall-Risk Resident: A resident with severely impaired cognition, dementia, multiple prior falls, and a care plan for a helmet, Merry walker, and 1:1 sitter fell while ambulating with the device after abruptly standing and losing balance. CNA 1 stated she had not received in-service training or a report on the resident's risks or the safe use of the walker, and the resident sustained a nasal fracture and forehead laceration requiring transfer to a GACH.
LPNs Assigned Wound Care Without Competency Assessment
Penalty
Summary
Nursing staff were assigned to provide wound care to residents without having their competencies assessed or receiving wound care training. During interviews, S10LPN stated he was providing wound care to assigned residents, but the facility had not assessed his competencies or provided training before assigning him wound care responsibilities. S8LPN stated she was a recent graduate with limited clinical experience, had no certifications or educational background in wound care management, did not feel comfortable providing wound care without proper education and training, and had not been assessed or trained before being assigned wound care duties. S7LPN and S9LPN also stated they were providing wound care to assigned residents despite having no certifications or educational background in wound care management, and both said the facility had not assessed their competencies or provided training before assigning them wound care tasks. S9LPN stated she did not feel comfortable providing wound care because of her lack of education and training in wound management procedures and protocols. S5IPSDC confirmed wound care responsibilities had recently been assigned to floor nurses after the wound care nurse position was eliminated, and S2IDON confirmed nursing staff were not provided education or training in wound care management and that the facility had no competency assessments or evaluations for S7LPN, S8LPN, S9LPN, and S10LPN to provide wound care.
Nursing Competency and Communication Failures
Penalty
Summary
Licensed nursing staff did not complete competencies on hire and did not demonstrate the skill sets needed to care for residents based on assessed needs. The facility assessment listed training and competencies for the nursing department, including monthly education, orientation and training for new hires, and competency skill sets such as identifying resident change in condition and diabetic blood glucose testing. Review of employee files showed RN #507 and LPN #518 did not have nursing competencies completed on hire, and the Regional RN confirmed the facility had not been ensuring all licensed nursing staff had nursing competencies on hire. For one resident with diagnoses including atherosclerotic heart disease, gastroenteritis and colitis, muscle weakness, a stage 3 sacral pressure ulcer, peptic ulcer, malnutrition, bradycardia, hypotension, and intestinal bypass status, a urine culture positive for infection was reported to the facility but was not communicated to the NP until 13 days later. The resident was later hospitalized and treated for bradycardia, unresponsiveness, and IV antibiotics for a UTI caused by ESBL Klebsiella pneumoniae and E. coli. For another resident with hemiplegia and hemiparesis following cerebral infarction, CHF, hypothyroidism, and a history of GI bleed, an order required blood glucose checks twice daily, but the MAR showed only one check on one day. A dietary technician documented abnormal BUN, creatinine, and GFR results and recommended review for IV fluids and change in condition, but progress notes showed no follow-up on that recommendation, and both an LPN and NP stated they were not aware of the IV fluid recommendation.
Lack of Mechanical Lift Competency for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff had the specific competencies and skill sets necessary to meet residents’ needs related to the use of a mechanical lift. A fall investigation showed that a resident sustained a witnessed fall from a mechanical lift during a transfer from a chair to a bed by two staff members. A provider progress note documented that the resident was being evaluated after the fall from a Hoyer lift and reported pain in the right upper extremity and bilateral hips, with a head strike also noted. The facility assessment, last updated 11/11/25, identified that residents required services including transfer assistance with a mechanical Hoyer lift and stated that staff would be trained and evaluated for competencies related to lift assistance. Review of four LNA training files showed that one LNA lacked documented training or competency for operating a mechanical Hoyer lift. An interview with a Support Aide revealed that she occasionally assisted LNAs with Hoyer lift transfers but had not received facility training on how to transfer or assist in transferring a resident. The facility Educator stated that the Support Aide’s role did not include transferring residents or assisting with transfers, especially with a mechanical lift, and confirmed that all direct care staff were required to complete specific training and annual competency assessment to operate a mechanical lift; she also confirmed that the LNA had no evidence of completing the mechanical lift competencies.
Nursing Staff Failed to Follow Oxycodone Medication Parameters
Penalty
Summary
LVN 1 failed to follow Resident 1's physician order for oxycodone 5 mg by mouth every three hours as needed for severe pain. Resident 1 was admitted with cervical spinal stenosis and diabetes mellitus, and the H&P dated 5/12/2026 described the resident as alert and oriented x4. The MDS dated 5/14/2026 indicated the resident's cognitive skills for daily decision making were intact and that the resident was independent with all activities of daily living. The MAR showed oxycodone was administered on 5/11/2026, 5/12/2026, 5/13/2026, and 5/23/2026 even though the recorded pain scores were 4, 4, 2, and 4, respectively. During interview and observation, LVN 1 stated a medication parameter was used for medication ranges and guidance on when to give certain medications, but was unable to explain the medication administration process when a medication had parameters or what to do if a resident was not within the parameter. LVN 1 stated the pain scale for oxycodone was 5-10, yet also stated oxycodone was given because the resident and family requested it and that giving it for pain scores of 2 and 4 was following doctor orders. The DON stated medication parameters were used for resident safety and that not following them could cause complications, medication toxicity, and the medication would not help for the medication purpose and resident's diagnosis. The facility's competency policy stated nursing staff competency includes areas such as communication, medication management, and pain management.
Missing Staff Orientation, Competency, and Performance Documentation
Penalty
Summary
The facility failed to ensure that orientation, annual competency skill assessments, and annual performance evaluations were completed for 3 of 3 licensed staff and 5 of 5 unlicensed staff reviewed. During record review and interview, Human Resource staff K stated she had only been at the facility for 1 month and that records were not kept up, were moved around, and were not filed in alphabetical order. The facility’s policy stated that competency evaluation is required for all care team members, that initial competency is evaluated during orientation, and that ongoing and annual competency evaluations occur based on training program evaluation, job performance evaluations, identified performance gaps, or regulatory requirements. Record review showed missing or incomplete documentation for multiple staff members. An LPN had an expired CPR card, another LPN had a skills validation checklist but no annual performance records, and an RN had no CPR card and no orientation skills checklist from the rehire date. Among CNAs, one had no skills checklist or orientation form, one had a skills assessment checklist but no annual performance review, one had a background check for the assisted living side of the building that was not rechecked for LTC/skilled care and no 2026 skills checklist or annual performance review, one had no orientation skills checklist, and one had a skills validation checklist but none for 2026 and no annual performance review. When asked whether any additional documents were available, staff K stated she would have to ask the DON, and the surveyor would only accept documents until the end of the survey exit conference.
Failure to In-Service CNA on Merry Walker Safety for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure CNA 1 was in-serviced and given clear instruction on the protocols for mitigating physical and environmental hazards, including falls, for a resident who had a history of falls and was using a Merry walker for ambulation. Resident 1 had diagnoses including encephalopathy, protein calorie malnutrition, dementia, muscle weakness, disorder of bone density and structure, a prior fracture of the fifth metacarpal of the left hand, Alzheimer's disease, anxiety disorder, depression, hypertension, and adult failure to thrive. The resident's MDS dated 5/15/2026 indicated severely impaired cognition and need for varying levels of assistance with activities of daily living, including supervision for upper body dressing, partial moderate assistance with toileting hygiene, showering, bathing, and personal hygiene, substantial/maximal assistance with lower body dressing, and dependence for putting on and taking off footwear. The resident's record showed 12 separate falls in the facility, and the care plan identified unavoidable fall risk related to gait and balance problems, dementia, and non-compliance using a walker, with interventions including a helmet during ambulation, a Merri walker for ambulation, and a 1:1 sitter. On 6/12/2026, CNA 1 was assigned to monitor and supervise the resident while ambulating with the Merry walker. CNA 1 stated the resident stopped to rest, sat on the walker seat for about 2 minutes, then abruptly stood, held the front of the walker, and started walking; the resident lost balance and fell face forward. CNA 1 stated she had worked at the facility for 1 month and had not received in-services on the risks and hazards associated with a resident using a Merry walker, and she was not provided a report explaining why the resident was using the device or what behaviors and risks to watch for. The resident sustained a nasal fracture and a laceration to the forehead and was transferred to a GACH for further evaluation and management.
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