Medication Error Due to Inadequate Physician Review
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, including medications, which led to a medication error. A resident with bilateral knee osteoarthritis and muscle weakness was prescribed Tylenol 1000 mg every 8 hours by an Orthopaedic Surgery Specialist. However, the resident was already receiving Tylenol 8-hour oral tablet extended release three times a day for pain, with a maximum dosage of 3 grams per 24 hours. This oversight resulted in the resident receiving over 15,000 mg of Tylenol over three days, significantly exceeding the recommended dosage. The error occurred because the Certified Nurse Practitioner, working in coordination with the resident's attending physician, signed off on the new order without realizing the existing Tylenol prescription. Interviews with staff revealed that the resident should not have received more than 3,000 mg per day due to potential liver damage. Despite the excessive dosage, subsequent laboratory testing and monitoring showed no concerns with the resident's condition.
Plan Of Correction
1. The facility cannot retroactively correct the failure to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services to assure resident safety or maintain the highest practicable physical well-being of each resident. All Tylenol orders will be updated to ensure max dose/24 hrs alert is noted on the order to prevent from over medicating. All orders must be handwritten and signed by the provider on facility order sheets; there will be no more taking After Visit Summaries and circling orders, they must be written out on the correct order sheet or verbal can be taken with readback to prevent confusion with new orders. 2. DON/designee will perform a house sweep on all residents who are on Tylenol to ensure dosing is correct, max dose alert on order, and there are no duplicate orders. 3. DON/designee will re-educate nursing staff on 5 rights of medication administration, and will have updated competencies over the next 90 days. Nursing staff will also be educated on Tylenol dosing, including max dose in 24 hours. Nursing staff and providers (MD's, CRNP's, PA-C's) will be educated on our Physician Order Entry-Clinical System Process which reviews the following topics: guidance/expectations of order entry, date required prior to order entry, orders and interim order entry, order alerts, custom medications, dispense as written, practitioner read back, drug recalls, duplicate orders, utilizing the lab logs, and additional topics which include respiratory, dietary, etc. 4. DON/designee will perform weekly audits x4 on residents batch orders (standard orders) to ensure they are appropriately placed, no duplicates. Batch orders include medications like Tylenol, MOM, stool softeners. This will hopefully minimize duplicate orders for commonly ordered medications as mentioned above. Audit will contain 8 residents per week. 5. Results will be reported to QAPI for review and further recommendations if needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A physician’s post-hospitalization progress note for a resident who had recently been treated for severe sepsis, severe hypernatremia, constipation, and had a PEG tube placed failed to document the hospitalization, the reasons for admission, the hospital diagnoses, or the new PEG and tube-feeding status. Instead, the note contained a general review of systems and physical exam with an assessment of CVA and constipation, without reflecting the recent acute conditions or significant change in nutritional route.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
The facility failed to ensure that a physician consistently documented required visit notes, including review of the total program of care, for four residents under one physician’s care. Over extended periods, the EHR contained only sporadic or no physician progress notes for these residents, despite the physician reporting that he visited them every other month and was in the building weekly. During the same time, multiple visits by an NP and a PA were documented. In interviews, the DON confirmed the physician’s regular presence but could not explain the missing notes, and the physician acknowledged that his notes were not in the records and stated he must not have entered them. The Administrator reported there was no policy addressing clinical record accuracy or ensuring that physicians documented a note after each visit.
The facility failed to ensure the attending physician documented required monthly visits with signed and dated progress notes for four residents. Records for residents with diagnoses including dementia, bipolar disorder, functional quadriplegia, conversion disorder, GERD, anxiety, and HTN showed extended gaps with no physician progress notes, and the NHA confirmed the missing documentation during interview.
A resident's clinical record lacked evidence of the last time the physician reviewed, signed, and dated the resident's orders. The DON confirmed the missing physician signature documentation and stated that orders should be reviewed and signed at required physician visits, including on admission and at set intervals thereafter. The resident had diagnoses including GI hemorrhage, HTN, and TIA/cerebral infraction.
Incomplete Post-Hospitalization Physician Documentation After Sepsis and PEG Placement
Penalty
Summary
A physician failed to complete a thorough post-hospitalization examination and progress note for a resident following readmission from the hospital. The resident, an elderly female long-term resident with a history of stroke with right-sided paralysis, aphasia, oropharyngeal dysphagia, behavioral disturbance, seizures, urinary and bowel incontinence, and severe cognitive impairment (BIMS 99), had been hospitalized for altered mental status and returned to the facility after treatment. The hospital discharge summary documented severe sepsis due to complicated UTI, severe hypernatremia likely due to poor oral intake and dehydration, combative behavior, severe constipation, an incidental pelvic mass requiring further outpatient MRI evaluation, and placement of a PEG tube for nutrition. On the post-hospitalization visit dated 02/17/26, the attending physician’s progress note documented a general review of systems and physical exam, including stable vital signs, normal HEENT, cardiovascular, respiratory, abdominal, and extremity findings, and an assessment and plan listing CVA with supportive care and constipation managed on the current regimen. However, the note did not indicate that the resident had been recently hospitalized, did not state the reasons for hospitalization, hospital course, or diagnoses, and did not mention that a PEG tube had been surgically inserted and that the resident would now be receiving tube feedings for nutrition. The surveyors determined that the physician’s documentation did not reflect the resident’s current health status on return to the facility, as required.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Ensure Physician Visit Documentation in Clinical Records
Penalty
Summary
The facility failed to ensure that a physician reviewed residents’ total programs of care and documented visit notes, including progress notes and orders, at each required visit for four of five sampled residents under the care of one physician. For one resident with hypertension encephalopathy, stroke, anxiety disorder, and other conditions, the electronic record showed only two visit notes from the primary physician over an approximately ten‑month period, despite the physician reporting that he saw the resident every other month. During that same timeframe, multiple visit notes were documented by NPs and a PA, but there were no additional physician notes between early June 2025 and late April 2026. For a second resident with pneumonia, dysphagia, anemia, atrial fibrillation, hypertension, diabetes, and severely impaired cognition, record review from mid‑January to late April 2026 revealed no physician visit notes from the primary physician, although numerous visit notes were entered by a PA. A third resident with lymphedema, hypertension, hyperlipidemia, COPD, cellulitis, and moderately impaired cognition had no physician visit notes from admission through late April 2026, while NPs and a PA documented several visits during that period. A fourth resident with anxiety disorder, hyperlipidemia, bipolar disorder, neuromuscular bladder dysfunction, and fibromyalgia likewise had no physician visit notes from admission through late April 2026, despite multiple NP and PA visit notes. In interviews, the DON stated that the physician was in the facility weekly to see his residents and could not explain the absence of physician progress notes for the affected residents. The physician confirmed he was in the facility weekly, that he alternated visits with his NP and PA, and that he believed he had seen all four residents numerous times, including in February 2026, but acknowledged that his notes were not present in the electronic records and stated he “must not have put a note” in the records. The Administrator reported that she checked the electronic records after physician visits but noted that providers often delayed entering notes and also stated there was no facility policy on accuracy of clinical records or ensuring that physicians wrote a note after each visit. The report states that this deficient practice could place residents at risk for physician‑identified concerns, inadequate monitoring of medical conditions, and miscommunication with other health care providers.
Missing Physician Progress Notes for Required Visits
Penalty
Summary
The facility failed to ensure that the attending physician documented required monthly visits by writing, signing, and dating a progress note for each visit for four of 14 residents reviewed. Facility policy stated that attending physicians were to visit residents once monthly and document a progress note related to the visit. Review of clinical records showed that Resident R1, who had diagnoses including dementia, Wernicke encephalopathy, and high blood pressure, had physician progress notes dated and signed on several dates, but the record lacked evidence of any physician progress notes between 10/23/24 and 7/16/25, a nine-month period. Resident R2, with diagnoses including bipolar disorder, obstructive and reflux uropathy, and functional quadriplegia, had a last physician progress note dated and signed on 9/28/25, with no evidence of any physician progress notes between that date and 4/23/26. Resident R6, diagnosed with conversion disorder, GERD, and high blood pressure, also had no physician progress notes between 9/18/25 and 4/23/26. Resident R30, with diagnoses including dementia, anxiety, and high blood pressure, had no physician progress notes between 6/17/25 and 4/23/26. During interview, the Nursing Home Administrator confirmed that the records for these residents lacked the required physician progress notes at the time of review.
Physician Orders Not Signed and Dated
Penalty
Summary
The facility failed to ensure that the physician signed and dated all orders during visits for one resident, R94. Facility policy stated that the attending physician would visit residents in a timely fashion consistent with applicable state and federal requirements, and that physician orders and progress notes would be maintained in accordance with OBRA regulations and facility policy. R94 was admitted on 2/17/26 with diagnoses including gastrointestinal hemorrhage, hypertension, and transient ischemic attack/cerebral infraction. Review of R94's clinical record found no evidence of the last time the physician reviewed, signed, and dated the resident's physician orders. During interview, the DON confirmed that the physician orders for R94 lacked evidence of physician review and signature, and stated that physician orders should be reviewed and signed with every physician visit on admission, then every 30 days for the first 90 days, then every 60 days.
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