The March incident at Northern Manhattan Rehabilitation and Nursing Center left Resident #4 without the prescribed Tylenol and x-ray that Physician #1 had ordered by telephone. The resident's blood pressure measured 184/110 with a pulse of 110 when transferred to the hospital three days later to rule out deep vein thrombosis and altered mental status.
Registered Nurse #4 told inspectors during a July telephone interview that she assessed the resident on March 28 around 3:40 PM after Certified Nursing Assistant #3 reported the resident was complaining of pain. She observed the left arm was "slightly swollen" and larger than the right arm.
She called Physician #1, who ordered an x-ray of the left arm and 1000 milligrams of Tylenol for one dose. But Registered Nurse #4 couldn't enter the orders herself.
"They did not have any training on the Electronic Medical Record (Sigma), so they notified the oncoming (evening shift) Licensed Practical Nurse #3 to have the evening shift supervisor put the order in Sigma," the inspection report states.
The registered nurse told inspectors in a September follow-up interview that during orientation she attended an electronic medical record class with two other nurses in the educator's office. But the training was minimal.
"They were told by the educator there was no money for training Registered Nurses on the Electronic Medical Record," according to the inspection report. "They stated they were taught how to sign on to the Electronic Medical Record and that they informed the educator of the deficiency in training."
The nurse said she never signed any checklist for computer system training. Whatever she learned about the system, she picked up on her own while working on the resident floor. She had never been made aware of the facility's 24-hour report and had never documented on it.
When inspectors interviewed the facility educator on September 12, the educator disputed the nurse's account. The educator said Registered Nurse #4 "never reported that they were not comfortable with the Electronic Medical Record."
The educator described asking new employees about their computer experience during orientation. Those without experience received verbal instruction on "the basics for entering orders, progress notes templates, and the medication administration record."
Each new employee gets assigned a preceptor on their unit, the educator explained. The educator uses a checklist as a guide and signs off on computer competency after interviewing the new employee.
"If an orientee is not comfortable with the electronic medical record, the orientee would remain on orientation," the educator told inspectors.
But the Director of Nursing acknowledged the system failure during a telephone interview in October. The director confirmed that Registered Nurse #4 had received training on transcribing and picking up physician orders during orientation.
However, the director admitted they "became aware that Registered Nurse #4 did not transcribe the orders received by Physician #1 during their investigation and cannot provide information as to why Registered Nurse #4 did not transcribe the order into the electronic medical record."
The director also confirmed "there were no documented evidence that the medication was given since the order was not transcribed."
The facility's orientation process, according to the Director of Nursing, spans multiple days. New staff receive classroom instruction on policies and mandatory training on topics like abuse and elopement prevention on the first day. On the second day, new employees shadow experienced staff based on their credentials.
The experienced nurse is supposed to orient new staff on rounding procedures, the 24-hour report, treatments, physician orders, and entering orders into the electronic medical record. The nurse educator checks on new employees daily and discusses whether they need additional orientation.
The director said the nurse educator conducts evaluations on medication administration, transcribing orders, and picking up orders before signing off that a new employee is competent.
Despite this described process, Registered Nurse #4 told inspectors she was never made comfortable with the computer system and received inadequate training on critical functions like entering physician orders and using the 24-hour report.
The incident came to light through a complaint investigation. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Resident #4's condition deteriorated over the three days following the missed orders. A transfer summary note by Registered Nurse #1 on March 31 documented the resident was being sent to the hospital to rule out deep vein thrombosis in the left upper extremity and altered mental status.
A nursing note by Licensed Practical Nurse #6 recorded that Resident #4 left for the hospital at 1:55 PM on March 31. No bruising was noted on the resident, and staff reported no falls had occurred.
The inspection report does not indicate whether the evening shift supervisor successfully entered the physician's orders after Registered Nurse #4 requested assistance, or whether the resident ever received the prescribed Tylenol and x-ray before the hospital transfer.
The case highlights a gap between the facility's stated orientation procedures and what actually happened with at least one registered nurse. While administrators described comprehensive computer training and competency verification, the nurse who discovered the resident's swollen arm said she lacked basic skills needed to enter critical physician orders into the medical record system.
The registered nurse's account suggests she informed the educator about inadequate training, but the educator told inspectors no such complaint was ever made. This disconnect left a resident without prescribed treatment for three days while suffering from significant swelling and elevated vital signs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northern Manhattan Rehabilitation and Nursing Ctr from 2025-10-16 including all violations, facility responses, and corrective action plans.
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