Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with a history of hip fracture, muscle weakness, COPD, osteoporosis, and moderate cognitive impairment experienced an unwitnessed fall and was found on the floor next to an unlocked wheelchair, reporting elbow pain with bruising and swelling. Later the same day, an Interact evaluation documented pain and marked bruising and swelling in the right elbow, trochanter, and thigh, and the physician ordered immediate X‑rays of the right elbow, femur, and hip. Due to inclement weather, the X‑ray company did not come, and despite the resident’s ongoing pain and the documented injuries, the resident was not sent to the ER for imaging that day. X‑rays obtained the following morning showed acute fractures of the right hip and right elbow, and subsequent hospital evaluation identified additional pelvic and humeral fractures, confirming that there was a significant delay between the fall and the identification of these injuries.
A resident with vascular dementia, kidney disorders, a history of UTIs, and frequent incontinence returned from the hospital with an acute UTI diagnosis and instructions to start cephalexin 500 mg PO four times daily for seven days after receiving Rocephin. Facility documentation showed no evidence that the AVS was reviewed or obtained from the hospital or the resident’s POA, and there was no record of the resident refusing care or refusing to provide the AVS. A physician order for cephalexin was not entered until two days after readmission, and the MAR showed the antibiotic was not started until that time. An RN reported being unaware of the UTI or need for antibiotics, while the DON acknowledged the lack of documentation and attempts to obtain the AVS, and the resident denied refusing to share the AVS.
Surveyors found that the facility failed to provide ordered and coordinated care in several cases. A hospice resident with severe cognitive impairment was lowered to the floor during a nighttime episode, after which staff documented no suspected injury and did not notify hospice, despite the resident later reporting high pain scores, visible bruising, and difficulty bearing weight; imaging was delayed and ultimately revealed a left femoral neck fracture requiring surgery. Another resident with severe cognitive impairment and cardiovascular disease had antihypertensive medications repeatedly held per BP parameters without provider notification, and on one occasion the medications were given despite BP below the ordered threshold. A third resident with dementia and a diabetic foot wound had daily wound care documented as completed, but observation showed a dressing dated two days earlier, indicating the treatment was not performed as ordered. Additionally, two residents with dementia and mobility limitations had physician orders or care plan interventions for perimeter mattresses that were not timely implemented, with one mattress topper left in a bag in the room and another order delayed, and staff, including the DON and an LPN, were unaware of the status of these safety devices.
A resident with multiple complex conditions, including CHF with CKD stage 3, COPD, diabetes, fractures, and protein-calorie malnutrition, had a physician order for 1L NS IV at 100 cc/hr for dehydration that was not implemented in a timely manner. An LPN documented the order, but the IV was not started until later by an RN, who reported that prior nurses had refused to hang the IV. The DON, Interim DON, and ADON all confirmed that the IV infusion was not initiated within a timely period after the order was received, despite facility policy requiring the nurse who takes the order to execute it or ensure a safe hand-off.
The facility failed to coordinate and document hospice services for a resident on hospice, as there was no hospice care plan or visit documentation in the chart or hospice binder, and staff were unaware of hospice visit schedules or the hospice plan of care despite a policy requiring communication with hospice. The facility also did not provide ongoing assessment and monitoring for non-pressure skin conditions in two residents: one with nummular eczema treated with clobetasol but lacking follow-up documentation, weekly skin assessments, or a care plan, and another with multiple abrasions, scabs, and a surgical incision whose skin impairments were not comprehensively assessed or measured weekly as required by the wound/skin policy.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Delay in Diagnostic Evaluation and Treatment After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and services following a resident’s unwitnessed fall. The resident had been admitted with a nondisplaced intertrochanteric fracture of the right femur, muscle weakness, COPD, osteoporosis, and avascular necrosis, and had moderate cognitive impairment. On the date of the incident, staff heard the resident yelling and found her sitting on the floor, leaning on the wheel of an unlocked wheelchair beside the bed. She reported right elbow pain, and staff noted bruising, swelling, and normal range of motion. She was assisted back to bed. An Interact Change in Condition Evaluation later that evening documented marked localized bruising, swelling, or pain not only in the right elbow but also in the right trochanter and right thigh, and indicated the resident had pain. Following the fall, the resident complained of right hip and upper leg pain and requested that staff call her brother. The physician was notified and immediate X‑rays of the right elbow, right femur, and right hip were ordered. However, the X‑rays were not obtained that day because the contracted X‑ray company could not come to the facility due to inclement weather. The DON confirmed that, despite the inability of the X‑ray company to respond, the resident was not sent to the ER that day to obtain imaging as an emergency measure. The Medical Director acknowledged awareness that the X‑rays were delayed until the following day and attributed the delay to the X‑ray company’s availability. The X‑rays were finally completed the next morning and revealed an acute intertrochanteric fracture of the proximal right femur and an acute comminuted fracture of the olecranon process of the proximal ulna, with associated osteopenia, joint effusion, and soft tissue swelling. Subsequent hospital evaluation identified additional fractures involving the right superior and inferior pubic rami and redemonstration of an impacted proximal humeral fracture with evidence of healing. The resident’s brother confirmed that nearly 24 hours elapsed between the fall and the discovery of the fractures, and he expressed concern about the delay in treatment. The facility’s Managing Falls and Fall Risk policy stated that staff would try to minimize complications from falling, but in this case, the resident did not receive timely diagnostic evaluation and related care after the fall when the ordered X‑rays could not be obtained as planned.
Failure to Implement Hospital Discharge Orders for UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure continuity of care and timely implementation of hospital discharge orders for a resident treated for an acute urinary tract infection (UTI). The resident, who had vascular dementia, kidney and ureter disorders, a kidney cyst, a history of UTIs, and frequent urinary and bowel incontinence, was moderately cognitively impaired and required substantial assistance with toileting. A hospital after visit summary (AVS) documented diagnoses of kidney stone, kidney cyst, and acute UTI, with instructions to initiate cephalexin 500 mg by mouth four times daily for seven days following a dose of Rocephin. The hospital record also noted a left renal calculus with partial obstruction and abnormal urinalysis findings. Upon the resident’s return to the facility, a progress note recorded the readmission, but from that date until three days later there was no documentation of refusal of care or refusal to provide the AVS. The physician order for cephalexin 500 mg four times daily for seven days was not created until two days after the resident’s readmission, and the medication administration record showed the antibiotic was not started until that later date, with the first dose given upon rising. A registered nurse interviewed denied knowledge of the resident’s UTI or the need for antibiotic therapy upon readmission. The DON stated that the resident had refused to provide the AVS, but confirmed there was no documentation of such refusal and no evidence that staff attempted to obtain the AVS from the hospital or contact the resident’s power of attorney, who had been present at the time of hospital admission. The DON also confirmed that the resident returned with a diagnosis of acute UTI and an order to start cephalexin four times daily, which was not initiated until days later, and was unsure if the antibiotic was available in the emergency box. In contrast, the resident reported being welcoming and denied refusing to give staff the hospital AVS.
Failure to Follow Orders, Monitor Changes in Condition, and Implement Safety Devices
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and goals, as well as failures in comprehensive monitoring after a change in condition. One hospice resident with severe cognitive impairment was lowered to the floor from bed during an early morning episode in which she believed her bed was on fire. Staff documented no pain, no change in range of motion, and no suspected injury immediately after the incident, and planned only to monitor for pain and bruising. Hospice was not notified of the incident at that time. Over the next several days, documentation showed increasing complaints of left hip and leg pain with pain scores up to eight and nine out of ten, bruising to the left buttock and knee, and repeated administration of PRN acetaminophen, which staff recorded as effective. The NP noted soreness and bruising, low suspicion of fracture, and initially ordered but then cancelled x‑rays after discussion with staff, based on the belief the resident had been lowered rather than fallen and had no uncontrolled pain. Hospice staff later assessed the resident, observed significant pain and favoring of the left leg, and requested imaging; x‑rays eventually revealed a probable subcapital fracture of the left femur, and subsequent hospital evaluation confirmed an acute impacted intracapsular subcapital femoral neck fracture requiring surgical fixation. The resident’s son and hospice nurse reported that the resident had complained of pain since the incident, that the facility delayed notifying the son of the event, and that hospice had to reiterate the need for imaging. Another deficiency involved a resident with severe cognitive impairment and multiple cardiovascular diagnoses who had physician orders for three antihypertensive medications (Amlodipine, Hydrochlorothiazide, and Lisinopril) to be held if systolic blood pressure was less than 120. The MAR showed numerous blood pressure readings below the ordered threshold throughout the month, resulting in the medications being held on multiple occasions, including three consecutive days. There was no documentation that the physician or NP was notified of these repeated medication holds. Additionally, on one date when the systolic blood pressure remained below 120, all three medications were administered instead of being held, contrary to the physician’s parameters. The DON confirmed that the provider had not been notified of the repeated holds and that the medications should have been held on the date they were administered. A further deficiency concerned a resident with diabetes, dementia, and a left dorsal foot wound who had a physician order for daily wound care with normal saline, Medihoney, calcium alginate, and appropriate dressings. The TAR for the month showed the treatment as completed daily; however, during observed wound care, the kerlex dressing on the resident’s foot was dated two days prior, indicating the dressing had not been changed as ordered. The LPN performing the dressing change confirmed the date and believed the dressing was to be done daily and as needed, revealing a discrepancy between documentation and actual practice. Additional deficiencies involved failure to implement ordered perimeter mattresses for residents at risk for falls or needing defined bed boundaries. One resident with dementia, muscle weakness, and dependence for transfers had a physician order in place for an air perimeter mattress for several months. Observations showed a bag containing a perimeter mattress topper sitting on the resident’s chair rather than on the bed, and staff, including the LPN and DON, were initially unaware of what was in the bag or that it needed to be applied. The DON later confirmed that the perimeter mattress order had been in place since January and that the topper should have been on the bed. Another resident with dementia and cognitive deficits had a care plan intervention for a bari‑bed with perimeter mattress and a later physician order for a perimeter mattress to assist with bed boundaries. The DON stated she was unsure when this resident actually received the mattress and that the physician order was not entered until weeks after the care plan intervention was documented, indicating a delay in implementing the ordered safety device.
Failure to Timely Implement Physician Order for IV Fluids
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of a physician’s order for IV fluids for one resident. The resident had multiple significant diagnoses, including age-related osteoporosis, hypertensive heart and chronic kidney disease with heart failure stage 3, COPD, type 2 diabetes mellitus, multiple right-sided rib fractures, fractures of the right ulna styloid process and shaft of the right radius, and protein-calorie malnutrition. A handwritten physician order dated 02/17/26 directed that 1 liter of normal saline be administered intravenously at 100 cc/hr. This order was signed by an LPN on 02/18/26. The MAR/TAR for 02/18/26 showed an order for 0.9% normal saline IV, 1 liter every 24 hours for dehydration, to run at 100 ml/hr starting at 6:30 p.m., and documentation indicated that an RN initiated a peripheral IV in the left antecubital space at that time with normal saline running at 100 ml/hr. Interviews revealed that the IV order was not carried out in a timely manner after it was received. The RN who started the IV stated that two nurses before her had refused to hang the IV and that she was told by the DON that they had to hang it, while the DON denied instructing any nurse to start the IV or having knowledge of nurses refusing to do so. The DON confirmed that the IV infusion order was not initiated timely on 02/18/26 and stated that the RN had all day to start the IV and administer the fluids per the physician’s order. The LPN who signed the order reported she might have taken the IV order and believed the dayshift nurse was to start the IV. The Interim DON confirmed that timely IV administration would be within a few hours of receiving the order and that this did not occur. The ADON also confirmed the IV infusion order was not initiated timely and denied knowledge of instructing a nurse to start the IV or of any refusals. The facility’s Physician Orders policy stated that the nurse who takes the physician order is responsible for executing it or providing a safe hand-off to the next nurse, which did not occur as required in this case.
Failure to Coordinate Hospice Care and Monitor Non-Pressure Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate treatment and care according to orders, resident preferences, and goals, specifically related to hospice coordination and skin/wound management. One resident with cerebral atherosclerosis, peripheral arterial disease, and adult failure to thrive had a physician order for hospice admission and a care plan noting hospice services and a poor prognosis. However, there was no hospice care plan or visit documentation from hospice nurses or aides in the electronic record, paper chart, or hospice binder. The LPN unit manager stated he did not know when hospice visits occurred or details of the hospice plan of care, and the administrator acknowledged the facility should collaborate with hospice and maintain a copy of the hospice care plan and documentation. The hospice RN confirmed hospice had admitted the resident but had not provided the facility with a care plan or nursing documentation, despite a facility policy requiring communication between the center and hospice to ensure quality care. The facility also failed to provide routine assessment and monitoring for a non-pressure skin condition in a resident with chronic diastolic CHF and stage 3 chronic kidney disease. This resident had a documented nummular eczema rash on the chest, back, arms, and abdomen, with an order for clobetasol ointment twice daily. After an initial assessment and treatment order, there was no further documentation or follow-up on the eczema in the medical record after a specific early December date, even though the clobetasol treatment continued. During an observation of incontinence care, the resident was noted to have multiple red, circular areas of varying sizes on the abdomen, chest, and arms. The LPN unit manager and the regional director of clinical services confirmed there was no nursing follow-up documentation, no weekly skin assessments, and no care plan addressing the nummular eczema. A third deficiency involved another resident with multiple medical conditions, including pain, muscle wasting and atrophy, gait abnormalities, peripheral vascular disease, osteoarthritis, iron deficiency anemia, and hypertension, who had several non-pressure skin impairments. Initial admission assessments documented scabs on both elbows and bruising on the left buttock without measurements, and after a hospital stay for spinal surgery and readmission, an abrasion on the left buttock, a scab on the left heel, and a surgical incision on the back of the neck were noted, with incomplete measurements and descriptions. The DON verified that, aside from the admission assessments, there were no comprehensive assessments or documentation of healing for any of the resident’s skin impairments, even though the resident was followed by a wound clinic. Corporate nursing staff confirmed that facility policy required a licensed nurse to complete a skin observation tool at least every seven days for any wound or skin impairment, and acknowledged that the resident’s non-pressure skin impairments were not assessed weekly by the facility or the wound clinic.
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