Failure to Obtain Physician Orders for Adaptive Device
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission, specifically for the use of a magnet device intended to manage seizure activity. The resident, a male with a history of sepsis, UTI, Marfan syndrome, and epilepsy, was admitted without an order for the magnet device, which was crucial for his care. The absence of this order was identified during a review of the resident's records, which showed no documentation of the device despite its mention in hospital admission paperwork. On the day of the incident, the resident was found in respiratory distress by a CNA, who then alerted a nurse. The nurse attempted to use the magnet device, which was provided by the resident's family, but there was no response from the resident. The nurse initiated CPR after the resident showed no pulse, but the resident was pronounced deceased shortly after EMS arrived. Interviews with staff revealed that the device was not known to the attending physician, and there was no formal order for its use, which was a critical oversight given the resident's condition. Further interviews with the facility's staff, including the DON and other nurses, confirmed that there was a lack of awareness and formal documentation regarding the magnet device. The family had brought the device to the facility, but it was not integrated into the resident's care plan or communicated to the physician. This lack of communication and documentation led to the facility's failure to provide appropriate care, contributing to the resident's death.
Penalty
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A resident with schizophrenia, bipolar disorder, and dysphagia was admitted and readmitted multiple times without the facility completing required comprehensive admission/readmission evaluations or verifying diet orders against prior records and swallowing needs. Initial and subsequent documentation showed inconsistent diet specifications (mechanical soft with nectar thick liquids vs. mechanical soft with thin liquids), with no evidence that staff contacted the hospital or prior group home to confirm the resident’s established puree/nectar thick diet. Required sections of the RD’s nutrition evaluation regarding prior therapeutic diet and familiarity with mechanically altered diets were left blank, and an admission evaluation was not completed after one readmission, while the existing diet order remained active without reassessment. Later, an IDT conference and SLP evaluation identified oral dysphagia and confirmed the resident’s prior puree/nectar thick regimen, underscoring that earlier diet orders and assessments had not been verified or aligned with the resident’s known swallowing deficits.
A resident with a Foley catheter, colostomy, and complex perineal and sacral wounds was readmitted from the hospital without specific wound care, catheter, or colostomy orders, and the facility did not obtain immediate physician orders for these treatments. The care plan referenced catheter use and treatments per MD orders but did not identify the colostomy, and the April physician order summary lacked Foley and colostomy care orders, with wound care orders not entered until several days later. Nursing notes documented the presence of a wound vac, surgical and graft sites, and intact catheter and colostomy, but staff acknowledged they had not contacted the MD, wound care physician, treatment nurse, or hospital at admission to clarify and obtain necessary orders. The facility’s own policy required confirmation and clarification of physician orders upon admission to ensure immediate care needs were met, but this process was not followed, and staff stated that the absence of admission orders could delay treatments and increase the risk of wound deterioration and infection.
A resident with COPD and emphysema received continuous oxygen therapy at 3 LPM via nasal cannula as documented in the care plan, but no corresponding physician order was found in the medical record. Staff, including an LPN, UM, RN, and DON, all acknowledged that a physician order should have been obtained and that existing chart-check processes should have identified the omission. Review of the facility’s physician order policy showed procedures for transcribing and verifying orders, yet these were not effectively applied to ensure a documented oxygen order for the resident.
Surveyors found that the facility did not review and implement hospital discharge instructions for two residents who used respiratory support devices. One resident with chronic respiratory failure and sleep apnea had a CPAP machine in the room and reported using it at night, but there was no corresponding physician order, care plan entry, or MDS documentation. Another resident with COPD and chronic kidney disease had an AVAP machine with detailed hospital transfer orders specifying pressure settings, respiratory rate, tidal volume, and O2 bleed-in parameters, yet no physician orders for AVAP use were entered in the medical record. The CNO confirmed that orders for both devices were missing, placing these residents at risk of delayed respiratory care and assessments.
A resident admitted for orthopedic aftercare following surgical amputation, with a history of kidney transplant and difficulty walking, arrived from the hospital with discharge orders for non–weight-bearing status to the right lower extremity and a requirement for a private room due to immunocompromised status from immunosuppressive medication. These orders were not transcribed into the facility’s physician orders, and thus non–weight-bearing and isolation precautions were not implemented. The DON reported that admission orders from the hospital were expected to be reviewed and clarified before arrival, but acknowledged that the admission nurse did not complete this review, leading to the omission.
A resident was admitted from the hospital with discharge paperwork that contained conflicting information about an IV Ceftriaxone order, which was listed as both discontinued in one area and as an active discharge order in another. The IV antibiotic was never started on the resident’s MAR, and the DON later reported that the resident was on hospice, had no IV access, and was not receiving IV antibiotics. Despite the facility policy requiring verification of any order that appears inappropriate for the resident’s condition, the admitting nurse did not contact the physician to clarify the admission orders.
Failure to Complete Admission Evaluations and Verify Diet Orders for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive admission and readmission evaluations and to ensure accurate, verified physician diet orders consistent with a resident’s swallowing needs. A resident with schizophrenia, bipolar disorder, and dysphagia was admitted with an admission evaluation and physician order indicating a mechanical soft diet with nectar thick liquids, despite hospital discharge documentation, nursing assessments, and progress notes lacking evidence to support the need for a mechanically altered diet. The facility did not document any contact with the transferring hospital or the resident’s prior group home to verify the resident’s previous diet consistency, swallowing history, or nutritional needs at the time of admission, contrary to facility policy and the 24-hour admission/readmission chart review checklist. Following a hospital transfer and readmission, the admission evaluation dated March 12, 2026, continued to list a mechanical soft diet with nectar thick liquids, while the physician’s order for that same date specified a mechanical soft diet with thin liquids. This inconsistency between the admission evaluation and the physician’s order was not verified, clarified, or supported by a documented assessment of the resident’s swallowing status. After another hospital transfer and readmission on March 16, 2026, the facility did not complete an admission evaluation as required by policy, and the prior physician order for mechanical soft texture with thin liquids remained active without documented review, clarification, or reassessment to ensure it reflected the resident’s current swallowing needs, prior diet consistency, or clinical condition. A Medical Nutrition and Hydration Evaluation completed by the Registered Dietitian on March 17, 2026, identified the resident’s current diet as mechanical soft with thin liquids but left blank the sections on therapeutic diet prior to admission and prior knowledge of mechanically altered diets, and did not document reconciliation of prior records, clinical history, or swallowing needs. An interdisciplinary care conference on March 18, 2026, attended by nursing, dietary, therapy, administration, and group home staff, documented the resident’s diet as puree with nectar thick liquids, and a subsequent Speech Therapy evaluation on March 20, 2026, recorded group home staff reports that the resident previously tolerated a puree diet with nectar thick liquids and identified oral dysphagia requiring Speech Therapy, with a recommendation for puree with nectar thick liquids. During interviews, the NHA and DON confirmed there was no documented admission evaluation for the March 16, 2026, readmission and no evidence that staff obtained or verified the resident’s diet status from the hospital or group home upon admission or readmissions to ensure accuracy of physician diet orders.
Failure to Obtain Immediate Physician Orders for Foley, Colostomy, and Wound Care on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement physician orders for a resident’s immediate care upon readmission, specifically for a Foley catheter, colostomy, and complex wound care. The resident was an adult male, cognitively intact with a BIMS score of 15, who had a urinary catheter, a colostomy, and abscesses in the groin and perineal areas. His care plan identified him as a new admission post-sepsis with goals to identify immediate health and safety needs and approaches that included catheter use for wound management, turning and repositioning, and treatments per physician orders; however, the colostomy was not identified in the care plan. The hospital discharge orders did not contain specific orders for wound care, Foley catheter care, or colostomy care, and only instructed that detailed wound care instructions be sent with the patient and that the wound vac be continued in the skilled nursing facility, along with a recommendation for frequent repositioning and pressure offloading. Record review showed that the resident’s April physician order summary contained no orders for urinary catheter or colostomy care, and wound care orders were not entered until several days after readmission. Nursing progress notes documented that the resident returned from the hospital with a wound vac in place and that the initial skin and systems assessment was deferred at the time of arrival. A later skin assessment documented surgical wounds to the coccyx, additional wounds on the perineum and scrotum, a skin-grafted site on the right upper leg, and suture markings on both upper inner thighs, as well as the dates of the last Foley and colostomy bag changes. Subsequent nursing notes described the resident’s colostomy and indwelling catheter as intact and noted the wound vac settings, but there were still no corresponding physician orders for catheter or colostomy care at that time. Interviews with staff confirmed that no wound care, Foley catheter, or colostomy care orders were obtained at the time of readmission. The treatment nurse stated that the hospital had not sent wound care orders and that she later obtained wound care orders from the facility’s wound care physician to resume previous orders, and then separately obtained wound vac orders, acknowledging that she should have restarted prior orders sooner. She also stated that the resident did receive wound care on two days that was not documented. The admitting RN reported that he did not think to call the physician to restart previous wound, urinary catheter, or colostomy orders, did not know who the wound care physician was, and did not contact the treatment nurse or the hospital to obtain orders. The clinical services director stated it was the facility’s expectation that any admitted resident must have orders for necessary care, including wound, urinary catheter, and colostomy care, and that daily orders needed to be clarified immediately. The facility’s own policy on physician orders required that a nurse review transfer records, call the physician to confirm and request additional orders as needed, and ensure that upon admission the facility had physician orders for the resident’s immediate care, but this process was not followed for this resident. The report states that this failure to have physician orders for the resident’s Foley catheter, colostomy, and wound care upon readmission could place the resident at risk for not receiving appropriate care and treatment services. The treatment nurse further stated that the risk of not having orders upon admission was that wounds might not receive treatment and could decline or become infected, and that colostomy and urinary catheter care could be missed, increasing the risk of infections. The clinical services director similarly stated that not having admission orders could delay treatments and result in a decline in the resident’s overall well-being and recovery.
Oxygen Therapy Implemented Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order for oxygen therapy upon a resident’s admission, despite implementing and maintaining oxygen as part of the resident’s care. The resident was admitted with diagnoses including an upper right humerus fracture with routine healing, fall, emphysema, and COPD. The discharge MDS showed the resident was cognitively intact with a BIMS score of 15/15. The resident’s Care Plan documented oxygen therapy at 3 LPM via nasal cannula continuously for COPD, with detailed interventions to monitor for signs and symptoms of respiratory distress and related complications. However, review of the resident’s Order Summary Report revealed no corresponding physician order for oxygen. During interviews, an LPN stated that residents admitted from the hospital should have their orders transcribed and reviewed with the physician, and that a resident on oxygen should have a physician order. A Unit Manager confirmed that residents on oxygen should have both an order and a care plan, and acknowledged that there was no oxygen order for this resident despite the care plan indicating its use. The RN described a three-step chart check process involving the admission nurse, UM, and DON, plus night shift checks, and stated that someone should have identified the missing oxygen order. The DON confirmed there was no physician order for the resident’s oxygen and stated there should be, and that the oxygen order should match the care plan. The facility’s policy on physician orders outlined processes for transcribing and verifying verbal orders, and required all orders to be signed monthly, but this process did not result in a documented oxygen order for the resident.
Failure to Implement Respiratory Device Orders on Admission
Penalty
Summary
The facility failed to ensure hospital discharge instructions were reviewed upon admission so that physician orders were in place to meet residents’ medical needs. One resident with chronic respiratory failure with hypoxia and obstructive sleep apnea was admitted with a CPAP machine present in his room and reported using it at night. Surveyors observed the CPAP machine on the resident’s dresser, and the resident confirmed nighttime use. However, the Chief Nursing Officer (CNO) later stated that there was no physician order for the CPAP, and it was not included on the resident’s care plan or Minimum Data Set (MDS), despite the resident’s diagnoses and reported use of the device. Another resident admitted with COPD and chronic kidney disease had an AVAP machine at bedside and stated she used it at night to help her breathe while sleeping. Review of this resident’s hospital transfer orders documented detailed AVAP settings, including IPAP and EPAP ranges, respiratory rate, tidal volume, and oxygen bleed-in parameters with humidification and SpO2 targets, as well as instructions for use each night. Despite these specific hospital discharge instructions, review of the resident’s medical record on a later date showed no physician orders for AVAP use. The CNO confirmed that the AVAP was not on the resident’s orders and acknowledged it should have been, and the survey findings stated that this failure placed the residents at risk of delayed respiratory care and assessments.
Failure to Implement Hospital Discharge Orders for Weight-Bearing and Isolation Status
Penalty
Summary
The facility failed to ensure that physician orders from a transferring hospital regarding weight-bearing status and isolation needs were accurately transferred and implemented for one admitted resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status requiring immunosuppressive medication, and difficulty in walking. Hospital discharge orders dated 10/09/25 included a non–weight-bearing order for the right lower extremity and a requirement for a private room due to immunocompromised status related to the kidney transplant. Review of the resident’s physician orders at the facility showed that the non–weight-bearing status for the right lower leg and the isolation precautions related to immunosuppressive medication were not present. In an interview, the DON stated that the resident should have had these physician orders in place per the hospital discharge instructions and that her expectation was that all hospital admission orders be reviewed and clarified before the resident’s arrival. The DON confirmed that the admission nurse did not review and clarify these admission orders, and as a result, they were not implemented.
Failure to Clarify Conflicting Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to clarify and implement admission medication orders for one resident when the resident was admitted from the hospital. The hospital discharge packet dated 12/13/25 included a discharge order for Ceftriaxone 2 grams IV every 24 hours through 1/2/26, but the resident’s December 2025 MAR shows that this IV antibiotic order was not initiated on the admission date. The DON stated that the resident returned from the hospital on hospice and, to his knowledge, did not have IV access and was not receiving IV antibiotics. Upon reviewing the hospital discharge packet, the DON noted that in one section the antibiotics were documented as discontinued, but in another section Ceftriaxone was listed under discharge orders, and acknowledged that the admitting nurse should have called to clarify the conflicting orders. The facility’s policy on physician orders for medications or treatments, dated 6/2022, requires that any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis be verified with the attending physician, which was not done in this case.
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