Failure to Remove PICC at Discharge and Failure to Assess and Report Resident Fall
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one male resident with cellulitis of both lower limbs, muscle weakness, hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease, the facility did not ensure removal of a peripherally inserted central catheter (PICC) line upon discharge after completion of IV antibiotics. His admission MDS showed a BIMS score of 13, indicating no cognitive impairment. The discharge summary and discharge assessment documented completion of IV antibiotics for cellulitis, no skin issues, and no special instructions, but did not mention the PICC line, and there was no order in the record for PICC removal. The resident’s care plan, which was closed shortly after discharge, reflected that he had been receiving IV antibiotics for cellulitis, but there was no documentation that the PICC was addressed at discharge. The attending MD later stated he was not aware the resident had been discharged with the PICC still in place until after the fact, and that standard of care is to remove PICC lines prior to discharge unless there is a specific reason to keep them. He stated the resident had completed antibiotic therapy and should have had the PICC removed prior to discharge. The DON reported she became aware the resident went home with the PICC still inserted and that she obtained a telephone order from the NP the following morning to remove it, then went to the resident’s home with another nurse to remove the line and assess the site. The family member reported noticing the PICC still in the resident’s arm that evening at home and calling the facility, and the resident himself stated he realized later that day that the PICC remained in his arm and then notified his family. The administrator stated his expectation that PICC lines be removed prior to discharge unless there is an order to keep them and that staff should have obtained an order to remove the line once antibiotics were completed. The nurse who completed the discharge assessment stated she knew the resident had been on IV antibiotics but did not remember or realize he still had a PICC line at the time of discharge. She reported that she did not see a PICC line when she discharged him and did not specifically look for one because he had completed his antibiotics, and she was not aware he went home with the line in place or that staff later went to his home to remove it. She stated that if a resident has a PICC at discharge, staff are supposed to notify the RN on duty because only RNs can remove PICC lines, but she did not notify the RN because she did not know the line was still present. The facility’s PICC line removal procedure, when requested, did not contain instructions or guidance on removal of PICC lines prior to discharge. The deficiency also involves the facility’s failure to assess, document, and report a fall and possible injury for a female resident with acute respiratory failure with hypoxia, type 2 diabetes, cognitive communication deficit, hypertension, and muscle weakness, whose BIMS score of 1 indicated severe cognitive impairment. Her care plan identified her as at risk for falls related to dementia, weakness, a foot ulcer, and unsteady gait/transfers, with a goal to minimize risk of injury. Progress notes from the period surrounding the alleged fall contained no entries documenting a fall or post-fall assessment. Several days later, a nurse performing a body assessment noted bruising on the resident’s right upper arm and pain with movement, documented these findings, and notified the NP and family, leading to x‑rays that showed an acute right humeral head fracture. A CNA reported finding the resident on her floor mat by the bed on an evening shift and hearing a thud just before discovering her on the floor. She stated she notified the charge nurse and that another CNA assisted in bringing the resident to the nurse’s station. Both CNAs reported that the nurse lifted the resident under her arms into a wheelchair and that they did not observe the nurse perform a physical assessment, take vital signs, or check pupils at that time. They stated the resident did not cry out or show facial expressions of pain and that they did not see visible bleeding. One CNA later informed the DON about the fall when she learned of the resident’s injury and discovered the fall had not been reported. The charge nurse involved stated he did not notify the MD, resident representative, or family about a fall because he believed the resident had not fallen and did not recall the CNA reporting a fall. He acknowledged that if a resident fell, the nurse would be responsible for notifying family and providers, completing an assessment, and doing an incident report, but reiterated he was unaware of any fall and therefore did not complete an assessment. The DON stated she learned of the fall from the CNA and that, during her interview with the nurse, he initially denied a fall had occurred and later said the resident had been found on her fall mat but he did not count it as a fall, so he did not report it or make notifications. The NP and MD both stated they were not informed of a fall at the time it allegedly occurred and described expectations that staff assess residents after falls and notify providers so that injuries can be identified and treated. The facility’s Fall Management System policy required that when a resident sustains a fall, a physical assessment be completed by a licensed nurse with results documented in the medical record, and that the attending physician and resident representative be notified of the fall and resident status.
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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