Deficient Ventilator Care and Physician Oversight
Summary
The facility failed to ensure that residents requiring ventilator care received ongoing medical supervision and oversight by a physician. This deficiency was identified for nine out of fifteen residents reviewed for ventilator care, indicating a systemic failure in the interdisciplinary approach and physician oversight. The lack of adequate implementation of policies and procedures to monitor and supervise the weaning process for mechanical ventilation, as well as responding to mechanical ventilation alarms and respiratory needs, increased the likelihood of serious harm, injury, or death. One resident, who was admitted with multiple serious health conditions including acute and chronic respiratory failure and was ventilator-dependent, experienced a significant change in condition during an attempted weaning process. The resident was not tolerating the weaning, as indicated by persistent low minute volume alarms, low respiratory rate, and grayish skin. Despite these signs, there was no documented physician assessment or evaluation to determine the resident's eligibility for weaning, no weaning parameter orders, and no notification to the physician about the change in condition. The resident was later found unresponsive and pronounced dead. Interviews with facility staff revealed a lack of clear protocols and communication regarding the weaning process and physician involvement. The respiratory therapist and nurse involved in the resident's care were unsure of who decided the resident was eligible for weaning and did not notify the physician of the resident's deteriorating condition. The facility's pulmonologist was not frequently present, and there was no documentation of their assessments or evaluations in the residents' medical records. This lack of oversight and documentation contributed to the deficient practice in the facility's ventilator care management.
Removal Plan
- The NHA notified the Medical Director of the incident.
- The Pulmonologist will complete physical assessments on all like residents to identify any changes in condition and confirm current ventilator settings.
- The Pulmonologist has received education outlining responsibility for oversight for respiratory care for all Ventilator residents including but not limited to completing physical assessments, monitoring ongoing care, documenting consultations/evaluations, providing orders for weaning for ventilator residents.
- The pulmonologist has agreed to round for the residents on the ventilator unit at least 2 times per week. She is available to take call 24 hours in coordination with Primary Care Provider.
- Ventilator orders sets are entered on admission.
- Oxygen: RUN @ L/MIN VIA N/C MASK TRACH HOURS PER DAY PRN CONTINUOUS.
- Assess stoma site and under trach collar.
- Trach Change. Trach brand: Trach size:
- Change trach collar/strap every 3 days and prn.
- Visual check of ventilator dependent residents per care plan and prn.
- Weaning prn, per physician order, or respiratory protocol.
- Enter time in minutes to complete airway equipment management task.
- Evaluation/Assessment of resident on (Vent/Tracheostomy).
- Oxygen saturation q shift and prn.
- Oxygen tubing/filter change every week. Enter time in minutes to complete task.
- Suction tracheostomy as needed.
- Resident/Resident Representative Education.
- Trach Care PRN (as needed).
- Trach tie change with baths and as needed.
- Settings: Mode: RR: PEEP: PS:
- Change circuits monthly and PRN. Enter time in minutes to complete circuit change task.
- Trach care every shift and as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with several weeks of itching and self-inflicted scratches to the arms and hands was observed actively scratching with deep scratches present, while documentation showed repeated episodes of pruritus and open skin areas. Nursing staff had previously obtained a short course of Triamcinolone cream and later left messages for the physician requesting systemic medication (cetirizine) and reporting continued scratching and inflamed areas, but no new orders or documented physician response were received despite multiple calls and faxes. This resulted in the resident not being under timely physician supervision or receiving updated treatment in response to ongoing symptoms.
A resident with a g-tube, moderate cognitive impairment, and multiple chronic conditions had care planning and provider orders that did not address several aspects of tube feeding and medication management. The care plan lacked details for actual coccyx skin breakdown, refusal of care, fluid-volume imbalance, HOB elevation timing, and monitoring for hypercalcemia, hypothyroidism, and hyperparathyroidism. Orders also lacked directions for electrolyte monitoring, I&O, fluid balance, medication interactions, adverse-effect monitoring, and when to notify the provider if the resident refused meds or treatments. The PA stated she relied on consultants and pharmacy for monitoring and was unsure of the electrolyte schedule or the nutrition team’s involvement.
A resident admitted after hip fracture repair, who was cognitively intact and full code, developed hypotension, unresponsiveness, and worsening respiratory status over the course of a morning. An LPN contacted a PCP who was not on call and obtained orders for IV fluids while the resident remained unresponsive with abnormal vital signs and escalating oxygen needs. The PCP later stated he did not recall the case, believed he had only been told about low blood pressure, and indicated he would have ordered ER transfer if informed of unconsciousness and respiratory decline. The DON stated that timely sepsis recognition and response is a nursing standard and acknowledged the transfer was not timely, while the facility’s President of Operations reported there was no policy on physician services or supervision. EMS documented a primary impression of sepsis with hypotension, and the death certificate listed sepsis as the cause of death.
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.
The facility failed to ensure physician orders were signed and implemented for two residents. One resident had significant weight loss and an RD recommendation for fortified supplements and weekly weights that remained unsigned by the physician, while another resident’s pharmacy review recommending an increase in Januvia and discontinuation of sliding scale insulin was signed by the MD but not clarified or updated in the chart, leaving the order at the prior dose. Staff reported ongoing delays in getting MD responses and unsigned recommendations returned.
A resident with osteomyelitis and multiple stage 4 pressure ulcers of the sacrum, ischium, and hip, who was on hospice and had detailed wound care orders in place, did not have documented routine examinations of these wounds by a licensed medical provider. Wound assessments showed stalled and improving wounds with undermining and tunneling, and an LPN reported that hospice directed treatments focused on comfort and infection control. However, review of progress notes over many months, along with a physician note and a hospice NP face-to-face encounter, showed references to decubitus and non-healing stage 4 ulcers but no documentation that the pressure ulcers were actually examined by a provider, resulting in the cited deficiency.
Failure to Obtain Timely Physician Response for Ongoing Pruritus and Skin Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician supervised and provided consultation or treatment after being contacted regarding a resident with ongoing pruritus and self-inflicted skin injuries. During an interview and observation, the resident reported itching for about three weeks, stated they had requested medication to help, and was observed scratching both arms, which showed deep scratches on the upper and lower arms. The resident’s care plan documented multiple episodes of self-inflicted scratches to the hands and forearm over several weeks, with interventions directing staff to report abnormalities, failure to heal, and signs and symptoms of infection or maceration to the physician. Record review showed that on 3/27/2026 a verbal order was received to restart scheduled Triamcinolone cream to the right arm and left shin daily for 14 days. A skin/wound note dated 4/5/2026 documented that the resident continued to have pruritus to all extremities, with one open area on the left hand and no signs of infection, and that a message was left for the provider questioning the need for systemic medication (cetirizine) to ease the pruritic issue and assist with sleep. A communication note dated 4/11/2026 documented a call to update the physician that there were no changes to the areas on the arms and legs and that the resident continued to scratch and areas remained inflamed, with staff “waiting on updated orders,” but no physician response or new orders were documented. In interviews, an RN and the DON confirmed there had been a delay in physician response despite multiple calls and faxes and that the physician had not yet responded to the request for treatment for this resident’s ongoing scratching and skin issues.
Failure to Manage G-Tube Care and Medication Monitoring
Penalty
Summary
The facility failed to ensure a physician assistant appropriately managed the care of a resident who required nutrition and hydration via a gastrostomy tube and who had complications related to tube feedings and medication administration through the g-tube. The resident had moderate cognitive impairment, used a walker, and required assistance with several activities of daily living. Her care plan addressed tube feeding and some general skin and incontinence issues, but it did not identify actual skin breakdown on the coccyx, refusal of cares and treatments, risk for fluid-volume imbalance, specific head-of-bed elevation requirements during and after tube feedings, or symptoms and monitoring related to hypercalcemia, hypothyroidism, and hyperparathyroidism. The resident’s orders included Vital Advanced Formula via g-tube, scheduled water flushes, and multiple medications administered through the g-tube, including levothyroxine, prednisone, iron-vitamin liquid, folic acid, apixaban, metoprolol tartrate, senna, cinacalcet, omeprazole suspension, and ascorbic acid. The physician orders lacked directions for monitoring electrolytes, accurate intake and output, fluid balance related to tube feedings and free water, medication interactions, prevention of adverse effects, ongoing monitoring for nausea, vomiting, and abdominal pain, and when staff should notify the provider if the resident refused medications or treatments. During interviews, the physician assistant stated the resident had a complicated GI tract and hyperparathyroidism causing hypercalcemia, and that symptom management was the primary direction of care because she was no longer a surgical candidate. The physician assistant also stated she did not plan to order follow-up bloodwork because she thought consulting services would monitor electrolytes, was unsure of the electrolyte monitoring schedule, was unsure how involved nutrition services were, and had not directly communicated with the consultant pharmacist about medication timing in relation to tube feedings. Another provider stated facility providers were expected to manage calcium levels after discharge and that medication interactions and administration times should be assessed by the facility provider and pharmacist.
Failure to Provide Adequate Physician Supervision During Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate physician supervision and direction for a resident who experienced a significant change in condition. The resident had been admitted following surgical repair of a hip fracture and was documented on the admission MDS as cognitively intact, fully oriented, and able to communicate needs, with a full code status. On the night before the event, the resident’s vital signs and neurological status were documented as stable, with no physical concerns noted. On the following morning, the resident developed hypotension, first identified around 6:27 a.m., when the weekend on‑call provider was contacted and ordered holding aspirin and antihypertensives, testing stool for blood, and hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had further declined, he was unresponsive to verbal stimuli, and his oxygen saturation was low on room air. Throughout the morning, nursing documentation showed that the resident remained unresponsive, with persistent hypotension, tachycardia, and declining respiratory status requiring escalating oxygen support. The LPN caring for the resident contacted the resident’s PCP, who was not on call, and obtained orders for IV fluids at 100 ml/hr and later additional IV fluids, which were implemented while the resident’s unresponsiveness and abnormal vital signs continued. The PCP reported that he did not recall the resident or the specific calls but stated he was not on call that day and believed he was likely only informed about low blood pressure, not about unresponsiveness or declining respiratory status. He stated that if he had known the resident was unconscious with worsening respiratory status, he would have ordered immediate transfer to the ER. The DON stated that sepsis recognition and rapid response are a nursing standard in the facility and acknowledged it would be very hard to say the resident was transferred in a timely manner. The facility’s President of Operations reported that the facility did not have a policy regarding physician services or supervision. EMS records later documented a primary impression of sepsis with hypotension, and the resident’s death certificate listed sepsis as the cause of death.
Failure of Physician Supervision and Wound Management for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical care was effectively supervised by a physician, in accordance with facility policy and regulatory requirements. The resident had multiple serious comorbidities, including end stage renal disease on hemodialysis, diabetes mellitus, and protein calorie malnutrition, and was assessed as having moderately impaired cognition and a moderate risk for pressure injury. Initially, the resident had no documented skin problems, but on 08/12/2025 an RN requested a wound care consultation without documenting an identified wound or notifying the attending physician. No wound assessment was documented until 08/14/2025, when the wound care nurse identified moisture associated dermatitis to the sacrum and bilateral buttocks and a physician ordered topical treatments for 30 days. Although a subsequent nursing note on 08/15/2025 documented skin openings to the bilateral buttocks and indicated that the wound nurse and physician were to evaluate, there was no documented evidence of wound progression, effectiveness of treatment, or clinical reassessment between 08/14/2025 and 11/29/2025, despite a later surgical note on 12/17/2025 describing a sacral wound with serosanguinous exudate and specific measurements. After the resident was transferred to the hospital and later discharged back to the facility, the hospital discharge record documented eight wounds, including a Stage III sacral ulcer, unstageable and deep tissue injuries to both hips, deep tissue injuries to both heels, dry gangrene of the left toe, a necrotic right great toe, gangrene of all toes, and a left bunion with partial thickness skin loss. On readmission, the facility nurse documented pressure wounds to the sacrum, bilateral hips, gangrene to all toes, and bilateral heels, but the physician’s history and physical documented only moisture associated skin damage to the sacrum and did not identify the Stage III sacral ulcer or the other seven wounds listed in the hospital discharge summary. A physician order for collagenase was written without specifying the body site, and the treatment administration record showed the treatment as given on two days without identifying where it was applied. The wound care nurse’s assessment on 01/05/2026 documented only a right hip superficial abrasion, moisture associated dermatitis to the sacrum, and unremarkable lower extremities and heels, which did not correlate with the hospital discharge assessment or the nurse’s admission/readmission note. Subsequent physician orders on 01/05/2026 addressed Medi-honey treatment for irritant contact dermatitis and Triad cream for a left hip abrasion, but there was no documented evidence of physician orders or treatment for four of the wounds: the right hip wound, left bunion partial thickness skin loss, and bilateral gangrenous toes. There was also no documented evidence of a podiatry consultation. The wound care physician assistant later documented assessments of the sacrum and left hip (identified as a Kennedy terminal ulcer) but did not assess the gangrenous toes or left bunion wound, stating they only examined areas directed by the wound care nurse. The readmitting physician stated they reviewed the hospital discharge record and saw moisture associated skin dermatitis but did not observe the hip wounds, attempted but did not document a refused lower extremity exam, and did not order podiatry because they did not assess the bandaged extremities. The attending physician for the unit reported never seeing the resident after readmission and was unaware of the multiple wounds and gangrenous toes, relying on the wound care team and unit nurses for communication. The medical director acknowledged reviewing the hospital discharge notes and seeing the list of wounds, stated that the readmitting physician should have ordered treatments for all wounds, and confirmed they did not physically examine the resident. Collectively, these documented omissions and incomplete assessments demonstrate that the resident’s medical care, particularly wound management, was not effectively supervised by a physician as required by facility policy and regulation.
Unsigned Physician Orders and Delayed Review of RD and Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure physician, physician assistant, nurse practitioner, or clinical nurse specialist orders were in place for the immediate care and needs of 2 residents reviewed for physician services. For Resident #5, the quarterly MDS dated 02/27/2026 reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. The RD’s Nutritional Risk Assessment, also dated 02/27/2026, documented a significant weight loss of 9.1% (14.2 pounds) in 1 month, with possible contributing factors including recent hospitalizations, fluid fluctuations related to BLE edema, and diuretic therapy. The RD recommended house shakes BID and weekly weights for 4 weeks, but the communication between the dietitian and attending physician showed Dr. K had not signed the diet recommendations. For Resident #3, the record reflected diagnoses including dementia and Type 2 diabetes, and the quarterly MDS dated 12/08/2025 showed a BIMS score of 15 out of 15. The pharmacist’s Medication Regimen Review dated 02/25/2026 recommended increasing Januvia to 100 mg and attempting to discontinue sliding scale insulin to reduce needle sticks and medication burden. Dr. K signed the medication regimen review on 03/09/2026, but the facility had not updated the resident’s orders by 03/19/2026, and Januvia remained ordered at 50 mg daily. During interview, the DON and Compliance Nurse stated pharmacy and RD recommendations were emailed to the DON or MDS Nurse to send to the doctor for signature, and the signed orders were then returned for entry into the medical record. They stated there had been many unsigned orders and that Resident #3’s orders were not updated because Dr. K had been called for clarification on his note and had not responded. The Compliance Nurse stated responses should take less than 3 days, and the MDS Nurse and RD both described ongoing problems with physician response times and getting recommendations signed. The facility policies reflected that physician orders must be signed and dated, that the physician must supervise each resident’s medical care, and that nutrition and drug regimen recommendations should be signed and returned by the physician.
Failure to Ensure Provider Examination of Stage 4 Pressure Ulcers for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed medical provider routinely examined a resident’s stage 4 pressure ulcers, despite the resident being under hospice care and having multiple complex wounds. The resident was admitted and later readmitted with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, and stage 4 pressure ulcers of the sacral region, right buttock, and left buttock. The resident’s MDS showed moderate cognitive impairment and four stage 4 pressure ulcers, two of which were present on admission or reentry. Wound assessments dated 3/11/26 documented stage 4 pressure ulcers on the left and right ischium, sacrum, and left rear hip, with some wounds described as stalled and others improving, and with undermining and tunneling present. Physician orders were in place for specific wound care treatments, including cleansing, packing, and application of Dakins-moistened gauze and foam dressings. During the survey, the wound care LPN reported that the resident was receiving hospice services and that hospice directed the wound treatments, focusing on comfort and infection control rather than healing. However, review of the resident’s progress notes from 5/1/25 through 3/12/26 did not show documentation that a provider had examined the resident’s stage 4 pressure ulcers during that period. When the surveyor requested the most recent date a provider evaluated the wounds, the facility produced a physician progress note from 6/26/25 and a hospice NP face-to-face encounter note from 2/28/26. Both documents referenced the presence of decubitus ulcers and non-healing stage 4 pressure ulcers, but neither documented an actual examination of the pressure ulcers. This lack of documented provider examination of the resident’s stage 4 pressure ulcers led to the cited deficiency.
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