Failure to Timely Notify Physician and HCP of Change in Condition: A resident with paraplegia, DM, a chronic stage IV pressure injury, and other chronic conditions reported new right-hand weakness and inability to grasp utensils at breakfast and again at lunch. Nursing assessed the resident but did not promptly notify the MD or HCP; the HCP was only informed later when she visited and noticed right-sided facial drooping. The resident was then sent to the ED and admitted with an acute CVA, right upper extremity weakness, right facial droop, and dysarthria.
Incomplete and inaccurate wound care documentation: A resident with frostbite-related wounds and daily wound care orders had missing nursing notes for refused or uncompleted dressing changes, and the TAR also showed wound care as completed when an LPN said she had not performed it. The DON confirmed there was no additional documentation supporting completion of the right toe dressing changes, and the record lacked documentation of wound status, refusals, and treatment completion.
A resident with multiple diagnoses, including pelvic fractures, CVA, MDD, anxiety, GERD, HTN, and HLD, had a care plan and nutrition eval documenting a preference for skim milk. The resident said staff never provided skim milk and told him/her only low-fat milk was available. The dietician confirmed skim milk was the stated preference and should have been provided, while invoices and kitchen observation showed only whole milk and 1% milk on hand, with no skim milk available.
Medication Order Omission During Admission Reconciliation: A newly admitted resident with CHF and acute kidney failure had a hospital order for Furosemide 80 mg daily, but nursing failed to transcribe the order correctly during admission reconciliation. The omission was missed by the second nurse review and the 24-hour chart check was not completed, resulting in three missed consecutive doses of the diuretic.
Failure to Send Individual Discharge Notice to Ombudsman: A resident with MS, major depressive d/o, anxiety d/o, and tobacco use was transferred to the ED for evaluation, but the facility did not send the Ombudsman a copy of the resident’s individual transfer/discharge notice. Instead, the DSW faxed a weekly report listing generic discharge locations, which did not include specific addresses, and stated she was unaware that the Ombudsman office required the actual notices.
A resident with MS, MDD, and anxiety disorder was transferred to the hospital after an altercation involving an electric wheelchair. On return, the hospital discharge summary called for risperidone 0.5 mg daily, but nursing did not clarify the order with the MD and instead transcribed facility orders for risperidone 0.5 mg in the morning plus 0.25 mg at bedtime. The MAR showed the resident received the extra antipsychotic doses for several days before the DON identified the transcription error.
Failure to Employ a Qualified Full-Time SW: The facility did not have a full-time qualified SW after the SW was suspended and later terminated, leaving only a Social Worker Assistant who was not licensed and did not meet federal qualification requirements. The Assistant handled discharge planning, progress notes, notices, and referrals without SW oversight, while many residents had MH diagnoses and some had SUD diagnoses.
Failure to Immediately Report Alleged Verbal Abuse: Staff did not follow the abuse policy requiring immediate reporting when a CNA alleged that an RN verbally abused a resident. The CNA said she witnessed the RN use derogatory language toward a resident with dementia and moderate cognitive impairment, and she reported it to a nursing supervisor, but the DON was not notified until weeks later after HR received an email from the CNA. The DON stated staff did not implement the facility’s abuse reporting policy for immediate notification.
A resident with progressive MS was being transferred with a mechanical lift when the battery died and the lift stopped while the resident was suspended in the sling. Staff attempted to move the lift manually instead of lowering the resident, and the resident’s head struck the bedrail, causing a scalp laceration that required five staples. Interviews showed the CNAs were not documented as trained on the lift and were unaware of the emergency release system.
Care Plan Missing Mechanical Lift Transfer Needs: A resident with progressive MS had an ADL care plan that stated he/she was dependent for transfers, but it did not document the need for a mechanical lift and two staff assist for all transfers. CNAs, nurses, and the DON all confirmed the resident was always transferred with a mechanical lift and two staff members, yet the care plan lacked those transfer details.
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