A resident with restless leg syndrome, chronic pain, anxiety, and post-stroke hemiplegia had ropinirole increased from 1 mg daily to 1.5 mg at bedtime after increased symptoms were noted. The resident had moderate cognitive impairment, and the POST and DPOA identified a family member as the legal representative. The DON stated the representative was not notified at the time of the med change and was only notified several days later, despite facility policy requiring notification when meds are altered and attempts within 24 hours.
Failure to Notify Physician of Critical Lab Results and Change in Condition: A resident with CKD, AFib, and anticoagulant therapy had critical low platelet counts, repeated low BP readings, and increasing confusion with hallucinations, but the record lacked documentation that the physician was notified of the STAT lab results or the abnormal vital signs. Family members reported the resident was not acting like himself, and the resident was later sent to the hospital with altered mental status, hypotension, hypothermia, thrombocytopenia, acute metabolic encephalopathy, and sepsis.
A resident with CHF, diabetes, COPD, and morbid obesity had a physician order for daily weights, but the record showed weights were documented only sporadically and most missed weights had no refusal documentation or provider notification. Staff interviews showed confusion about whether the order was active, and the DON stated the resident had a history of noncompliance with weights, fluid restrictions, medications, and treatments.
Failure to notify physician of new skin impairment. A resident with HTN, morbid obesity, edema, hemiplegia/hemiparesis, PVD, DM2, and CHF had intact cognition and a care plan calling for weekly skin checks and notification of the MD/family for any new skin breakdown. Weekly skin documentation did not reflect the bilateral buttock and coccyx impairment later measured by the DON, including a red area with an open area on one buttock and red areas on the other buttock and coccyx. Staff stated new open areas are measured and the DON, doctor, and family are notified, but the physician was not notified of the new skin condition.
Incomplete Weekly Skin Assessment Documentation: A resident with multiple chronic conditions, including DM, PVD, obesity, and hemiplegia, had orders and care plan interventions for weekly skin checks and wound treatment to the buttocks. Review of the chart showed weekly skin assessment forms that did not document the resident’s bilateral buttocks and coccyx skin impairment noted on the day of survey, even though staff and the DON described the areas and the facility policy required weekly wound documentation in PCC.
Unsafe and Unclean Unit Environment: The 200 unit had marred walls, chipped door trim, a large hole in a resident room wall, missing drywall near the offices, and dirt buildup on baseboards, floors, and around the elevator. The dining room and elevator area also had debris buildup, and the elevator door frame wrap was hanging off on both sides. An HSKP staff member stated the facility was down a housekeeper and floors should be cleaned daily.
Incomplete documentation of change in condition assessment: A resident with dementia, dysphagia, diabetes, and heart failure had difficulty swallowing meds and breakfast, pocketed pills, and was later unable to swallow crushed meds. Staff contacted the daughter, who asked that the resident be put back to bed, and later the resident became unresponsive and was sent out for evaluation. The chart lacked vitals and an assessment at the start of the change in condition, although a later note documented vitals and diaphoresis.
A resident with dementia and severe cognitive impairment, who required substantial to maximum assistance with transfers and was ordered to use a stand lift, was transferred during a shower without the prescribed device or a gait belt when staff felt the lift was unsafe. She later developed severe shoulder pain and was found to have a displaced proximal humerus fracture. The record contained conflicting accounts about whether she fell out of bed, and the investigation lacked documentation showing how or who removed her from the floor if that had occurred.
Failure to Document Neuro Checks After Unwitnessed Fall: A resident with dementia, HF, and weakness reported falling out of bed and later was found to have an impacted, displaced humerus fracture. The record did not show the required 72-hour post-fall neuro checks or follow-up assessments after the unwitnessed fall, and an LPN and the ED confirmed the documentation was missing.
A facility failed to accurately transcribe hospital discharge orders for two newly admitted residents. One resident with bipolar disorder and other mental health diagnoses did not have all ordered psych meds entered correctly, and the MAR did not match the discharge paperwork; the resident later reported withdrawal symptoms and behavioral outbursts. Another resident with HTN, CKD, dementia, and a pacemaker had discharge orders for antihypertensives and Vitamin D, but the MAR lacked hold parameters and the record lacked BP/HR monitoring documentation.
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