Failure to Provide Timely Emergency Response and Clinical Notification
Summary
The facility failed to ensure that services provided met professional standards for two residents, resulting in actual harm. In the first case, a cognitively intact resident with multiple diagnoses, including cancer and diabetes, was found on the floor after a fall, unable to move their arms or legs, and with a small amount of blood behind the head. Despite these significant symptoms, including complaints of nausea, numbness, and inability to maintain upper body balance, staff did not call emergency medical services. Instead, the resident was lifted by several staff members into a wheelchair and transported to the emergency room in the facility van, accompanied by a CNA and the activities director. Staff interviews revealed that the decision not to call 911 was based on cost and perceived convenience, even though the resident exhibited signs of a possible spinal injury and head trauma. The nurse practitioner was not notified of the fall or the need for hospital transport at the time of the incident. In the second case, another resident with complex medical needs, including malnutrition, fractures, chronic respiratory failure, and a urinary catheter, experienced a significant decline in condition. The care plan indicated the resident required extensive assistance for mobility and toileting, and monitoring for signs of urinary tract infection (UTI). Despite orders for laboratory tests and a urinalysis, the urine sample was not obtained as directed. Over several days, nursing staff documented decreased urinary output, increased drowsiness, and changes in mental status. When a nurse reported these changes and recommended hospital transfer, she was instructed by the staff development coordinator to wait for the night nurse's opinion, delaying the transfer. The nurse was also told not to contact the provider, and her ability to make clinical decisions was limited by management. The resident was eventually transferred to the hospital after further decline, but the nurse practitioner was not notified of the change in condition prior to transfer, and the urinalysis was not completed until arrival at the hospital. Facility policies required prompt notification of physicians and families following significant changes in resident condition, including falls and clinical deterioration. However, in both cases, there was a failure to follow these protocols, resulting in delayed medical evaluation and intervention. Staff interviews confirmed that decisions regarding emergency transfers were influenced by non-clinical factors such as cost and convenience, and that communication with providers was inadequate during critical events.
Penalty
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A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
A resident with peripheral vascular disease and a left above-knee amputation, who was moderately cognitively impaired and receiving PRN opioid analgesia for pain, had a Hydrocodone/Acetaminophen order changed from 10 mg/325 mg to 5 mg/325 mg every 6 hours PRN. The MAR for the month showed both the discontinued 10 mg/325 mg order and the new 5 mg/325 mg order, and review of the controlled substance declining count sheets revealed that nurses repeatedly removed 10 mg/325 mg tablets while documenting administration of 5 mg/325 mg on the MAR, and on two occasions removed 10 mg/325 mg tablets with no corresponding MAR entry. The NP confirmed the resident should have been receiving only the 5 mg/325 mg dose during this period, and the DON stated the discontinued 10 mg/325 mg supply and count sheet should have been removed when the order was changed.
Medication administration and ordering did not meet professional standards when an LPN incorrectly held an antihypertensive despite the BP parameter, disposed of an unadministered tablet in a resident’s room trash instead of using approved disposal methods, and failed to instruct a resident to rinse their mouth after a Breyna inhaler as ordered. Additionally, two PRN bowel medications for a resident with a colostomy were ordered for rectal administration, even though, according to an RN, this resident could not receive medications rectally.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with an order for Divalproex DR 250 mg, two tablets in the morning and three at bedtime, was instead given 500 mg tablets over an extended period after the contracted pharmacy dispensed the wrong strength. The MAR continued to reflect the 250 mg order and was signed daily as given, while nurses did not detect that the medication cards contained a different strength than the physician’s order. The resident later developed altered mental status and was sent to the ER, and a NP documented that the resident had been receiving the incorrect Divalproex dose. Staff interviews and facility policy confirmed that nurses were expected to verify the right dose by comparing the medication label to the MAR and order, but this verification process failed in this case.
Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Wrong Opioid Dose Administered After Order Change
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for an opioid pain medication, resulting in administration of the wrong dose multiple times. The resident involved had peripheral vascular disease and a left above-knee amputation and was moderately cognitively impaired, receiving PRN opioid medication for pain rated 6/10. A physician’s order for Hydrocodone/Acetaminophen 10 mg/325 mg every 6 hours as needed was discontinued and replaced with an order for Hydrocodone/Acetaminophen 5 mg/325 mg every 6 hours as needed. The November Medication Administration Record (MAR) showed both the discontinued 10 mg/325 mg order (effective until mid-month) and the new 5 mg/325 mg order starting mid-month. There was no documentation that the 10 mg/325 mg dose was administered during the first part of the month. After the dose change, documentation discrepancies showed that nursing staff removed the discontinued 10 mg/325 mg tablets from the controlled substance declining count while documenting administration of the 5 mg/325 mg dose on the MAR. On several occasions, nurses documented giving 5 mg/325 mg on the MAR while the declining count sheets showed removal of 10 mg/325 mg tablets, and on two occasions 10 mg/325 mg tablets were removed from the narcotic count with no corresponding MAR entry. Attempts to interview the involved nurses were unsuccessful. The Nurse Practitioner confirmed that during the relevant period the resident’s order was for 5 mg/325 mg and that the nurses removed 10 mg/325 mg tablets instead, resulting in the resident receiving the wrong dose. The DON stated that the discontinued 10 mg/325 mg declining count sheet and blister pack should have been removed from the medication cart when the order was discontinued.
Medication Administration and Ordering Did Not Meet Professional Standards
Penalty
Summary
The deficiency involves failures in medication administration and disposal that did not meet professional standards of quality. For one resident with multiple fractures, COPD, and hypertension, an LPN measured the resident’s blood pressure at 108/70 and then incorrectly held the ordered losartan, despite the physician’s order specifying to hold the medication only if the systolic blood pressure was less than 100. The same LPN was observed disposing of an unadministered tablet by dumping it from a medication cup directly into the resident’s room trash can and then discarding the cup in the same trash, contrary to her own statement that unused medications should be placed in a pharmacy-provided return box or a Drug Buster container. In addition, when administering a Breyna (budesonide-formoterol) inhaler to this resident, the LPN assisted with two puffs as ordered but did not instruct the resident to rinse their mouth afterward, nor did she provide education about the need to rinse, despite the physician’s order specifying to rinse the mouth after use. For another resident with emphysema, muscle weakness, a need for assistance with personal care, and a colostomy, the record contained physician orders for Dulcolax (bisacodyl) suppositories and Fleet enemas to be inserted rectally as needed for bowel care. A registered nurse stated that this resident had a colostomy and could not use any medications rectally, indicating that the ordered route for both the suppository and enema was incorrect for this resident’s condition. These findings were identified through observation, record review, and staff interviews, and demonstrate that medication administration and ordering did not consistently follow the five rights of medication administration and proper medication disposal practices.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Prolonged Administration of Incorrect Divalproex Dose Due to Pharmacy and Nursing Verification Failures
Penalty
Summary
Facility staff failed to ensure medications were administered according to professional standards of nursing practice for one resident. The resident had a physician’s order for Divalproex DR 250 mg, to be given as two tablets in the morning and three tablets at bedtime. Review of the MAR for May and June 2025 showed that this ordered regimen was documented as being administered daily. However, the resident’s clinical record and subsequent review revealed that the resident was actually receiving Divalproex DR 500 mg tablets instead of the ordered 250 mg tablets, resulting in administration of an incorrect dose over an extended period. On 6/20/25, the resident experienced a change in condition characterized by altered mental status, and the resident’s mother reported that the resident’s mental status and demeanor were off and requested transfer to the ER for evaluation. A nurse practitioner’s progress note dated 6/23/25, following the resident’s hospitalization, documented that the resident had been receiving the incorrect dose of Divalproex DR, specifically 500 mg daily instead of the 250 mg dose prescribed by the physician. There was no physician order in the medical record authorizing a change to Divalproex DR 500 mg. Interviews and documentation showed that the contracted pharmacy dispensed Divalproex DR 500 mg tablets on 5/18/25 instead of the ordered 250 mg strength, and that nursing staff continued to administer and sign off the medication on the MAR without identifying the discrepancy between the medication card and the physician’s order. The facility’s own medication administration policy and staff interviews indicated that nurses were expected to compare the medication label to the MAR and physician’s order, verify the right dose, and correct any mismatch, but this did not occur in this case. As a result, the resident received the wrong dose of Divalproex DR for a prolonged period before the error was identified.
Failure to Follow Ordered Urology Consultation
Penalty
Summary
The nursing facility failed to follow a physician-ordered urology consultation for a resident with urinary retention and a Foley catheter. The resident had been hospitalized for a left femur fracture, and hospital records showed the Foley catheter was removed and later reinserted after a failed trial without catheter. After discharge to the skilled nursing facility, the physician was faxed about discontinuing the Foley catheter and responded to start Alfuzosin for 4 days and then attempt a trial without the catheter. When that trial failed, the physician ordered the Foley restarted and follow-up with urology. Subsequent physician progress notes in February, March, and April documented referral to urology for further evaluation and care, and the resident’s catheter care plan addressed Foley care but did not include a plan for removing the catheter. During interviews, an LPN stated she knew the resident was expected to be seen by a urologist but it had not yet occurred and she was not sure why. The DON and ADON/IP stated the physician was expected to call the urologist to make the referral and that the urology office would then confirm the appointment time. The ADON/IP recalled discussing the urology consultation with the physician during January rounds, but confirmed she did not discuss the status of the consultation during February, March, or April rounds and had no other discussions with the physician about it. The DON acknowledged the failure to follow the January physician-ordered urology consultation was 100% on the facility.
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