A facility failed to ensure psychiatric assessment and services after a resident voiced suicidal ideation during PT eval and after another resident experienced a substantiated abuse incident and said they did not feel safe. Records showed no psych assessment after either event, despite existing behavioral health needs, psychotropic meds, and prior psych follow-up history.
A provider failed to timely sign and date a federally mandated visit note for a resident with multiple comorbidities, and the note included a physical assessment and vitals that staff said were pulled from a later change-in-condition entry after the resident had already been sent to the hospital. The DON and Medical Director stated the EMR auto-populated vitals and that a mandatory visit note was not appropriate once the resident was no longer in the building, while the Administrator said the facility did not audit provider note timeliness.
Two ventilator‑dependent residents with multiple pressure ulcers and complex medical needs did not have their total programs of care reviewed by an attending physician at required visits. For one resident, wound documentation and interviews showed discrepancies between the wound specialist’s recommended treatments and the pulmonologist’s signed orders, with no evidence that the physician reconciled or evaluated these differences despite ongoing purulent drainage and increased treatment frequency. For another resident, serial wound notes documented stagnant, draining sacral and buttock ulcers and labs showed progressively abnormal WBC, Hgb, and Hct values, while NPs ordered and adjusted antibiotics and topical treatments; however, the pulmonologist’s monthly note only mentioned pressure ulcers without addressing their unhealing status or abnormal labs. Interviews with the DON, NPs, medical director, pulmonologist, and administrator revealed conflicting understandings of who was the attending physician for ventilator‑dependent residents, and there was no clear physician oversight of the residents’ overall care, leading to the cited deficiency.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer that nursing staff and the IDT documented, including wound measurements and a plan to refer to an in‑house wound provider. At a required initial H&P visit, the attending physician documented no skin breakdown and described the skin as warm and dry, omitting any mention of the known heel ulcer and failing to document a plan of care or treatment for it, contrary to facility policy requiring review and documentation of the resident’s total program of care at each visit.
A resident with ESRD on hemodialysis, diabetes, and severe malnutrition developed moisture-associated skin damage to the sacrum and buttocks, for which topical treatment was ordered but not clinically reassessed or documented for effectiveness over an extended period, despite later evidence of wound deterioration. After a hospital stay, the resident was readmitted with eight documented wounds, including a Stage III sacral ulcer, bilateral hip wounds, heel injuries, gangrenous toes, and a left bunion wound. On readmission, nursing documented multiple wounds, but the physician history and physical noted only sacral moisture-associated skin damage, and a debriding agent was ordered without specifying the body site. A wound nurse assessment documented findings that did not match the hospital discharge summary or nursing admission note, and subsequent orders addressed only sacral dermatitis and a left hip abrasion, with no documented physician orders, assessments, or treatments for the right hip wound, left bunion wound, or gangrenous toes, and no podiatry consult. The wound PA later assessed only selected areas directed by the wound nurse, while the readmitting MD, attending MD, and medical director each acknowledged limited or no direct examination of the resident and incomplete follow-through on the documented wounds, resulting in a failure of effective physician supervision of medical care.
A resident with schizoaffective disorder, type 2 DM, and morbid obesity continued receiving Megestrol even after the consultant pharmacist recommended discontinuation and the MD agreed. The MAR showed ongoing administration, while the MD stated the NP reordered the medication and the DON could not produce the discontinuation order.
Erroneous provider documentation was found across multiple resident charts, including the same routine MD note appearing in several records, a provider visit note filed in the wrong resident’s chart, and a provider encounter note that was signed long after the visit. Residents involved had diagnoses including dementia, parkinsonism, schizoaffective disorder, and GI disorders, and the notes described routine assessments, comfort, participation in activities, and no abnormal findings after a witnessed fall.
The facility did not ensure the attending physician reviewed a resident’s total plan of care at required visits. A resident with hypotension, anemia, anxiety, and a seizure disorder had a Midodrine order with a hold parameter for systolic BP above 115 mmHg, but the MAR showed the drug was repeatedly given when BP was 120 to 142 mmHg. Monthly MRRs noted the irregularities, yet the DON, pharmacist, medical director, and attending physician stated the physician was not made aware of the repeated Midodrine errors.
A resident with chronic constipation did not receive a recommended medication after a GI consult, as the consult documentation was missing from the chart and the medication was never ordered. Interviews with the DON, LPN, and NP revealed inconsistent processes for reviewing and filing consults, leading to incomplete documentation and failure to implement the consultant's recommendation.
A resident with DM and recent influenza was observed on oxygen via nasal cannula, and nursing notes documented ongoing oxygen use while the resident was being weaned off. Although a PM&R note said the acute condition had resolved and oxygen could continue PRN, the MAR/order record had no attending provider order or indication for oxygen use. An RN stated an order should be present whenever oxygen is used, and the Medical Director reported no hypoxic reports had been received.
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