A resident with Type I DM and hyperglycemia was admitted with discharge orders to continue insulin Lispro via a patient-supplied insulin pump, but the facility did not add BG monitoring when transcribing the orders. The resident later became clammy and unable to talk, had repeated HI blood sugar readings, received Novolog per NP orders, and was transferred to the hospital after the MD evaluated the resident.
A resident with fractures, multiple falls, obesity, and moderate cognitive impairment was dependent on 2 staff and a hoyer lift for transfers and toileting, but staff moved her to the toilet without the hoyer when she was trying to get up urgently. During the return transfer, her legs gave out and she was lowered to the floor; the event was not promptly documented or reported, and she later developed new left lower-extremity fractures confirmed by x-ray and hospital evaluation.
The facility failed to ensure timely notifications and proper documentation for several residents. A resident with fractures was lowered to the floor during a transfer, but the incident was not promptly reported to management or the physician, and later imaging showed new fractures. A resident with diabetes had insulin orders left pending after a pharmacy change, resulting in missed insulin and no physician notification. Two residents with hypotension received Midodrine without proper BP parameters or documentation of physician notification when doses were given outside ordered limits.
A facility failed to ensure nail care was provided for two residents who needed ADL assistance. One resident with severe cognitive impairment and another resident who was cognitively intact but needed help with personal hygiene were both observed with long, jagged, soiled fingernails on multiple occasions. Staff said nail care should be done during showers or bed baths, but it was not completed as expected, and one resident reported asking for help without receiving it.
A facility failed to timely release a resident’s medical records to the resident’s representative. The resident had fractures of the right fibula and left calcaneus, and the records request was held up with the facility’s legal team while the family was not informed of the delay.
A resident with moderate cognitive impairment, a history of falls, and transfer orders for a Hoyer lift only was moved by staff using a stand-pivot approach when she urgently needed the toilet. During the transfer back to bed, her legs gave out and she was lowered to the floor, then later found to have new left fibula and ankle fractures. The CNA told an LPN about the incident, but it was not documented or reported to management at the time, and the NHA later stated the event was not reported to the State Agency when she learned the resident had fallen after being transferred incorrectly.
Failure to Follow Transfer and Toileting Care Plan: A resident with fractures, multiple falls, and total dependence for transfers and toileting was supposed to be moved with 2-person hoyer assistance, but staff instead used a gait belt and stand-pivot transfers to get her to the toilet and back. During the return transfer, her legs gave out and she was lowered to the floor before being placed back in bed with a hoyer. An LPN later did not document or report the incident, and the DON confirmed the resident was only supposed to be transferred with the mechanical hoyer.
Medication administration and monitoring were not carried out as ordered for three residents. One resident with DM had insulin orders changed after admission, but the replacement orders were not confirmed in time and doses were missed; an RN also did not notify the physician when insulin was unavailable. Two residents with hypotension received midodrine without proper BP parameters or required documentation, and one resident received doses outside ordered BP limits without evidence of physician notification.
A resident with type 2 DM was admitted with orders for mealtime insulin, bedtime insulin, and daily blood sugar checks, but the pharmacy’s substituted orders stayed in pending status and nursing staff did not confirm them at the start of shifts. As a result, the resident missed insulin doses and glucose monitoring, with elevated blood sugars documented, and staff did not notify the physician when the medications were not being given.
Failure to Protect Resident from Physical Abuse by Another Resident: A cognitively intact resident reported that another resident with dementia repeatedly entered her room uninvited, called her names, and struck her hand with a cane when she tried to block a blow to her face. Records and staff interviews confirmed the other resident had a pattern of wandering into female residents’ rooms, verbal aggression, and threats involving his cane, while the care plan lacked documented interventions for his room-entry behavior.
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