Delayed Notification of Positive FOBT Result: A resident with an ileostomy, scoliosis, fibromyalgia, and thyroid disease was sent to the hospital after a CIC with abnormal VS and later returned with a pneumonia dx. After a stool sample was ordered for C-diff/FOBT, the FOBT was positive for blood, but the resident was not notified for several weeks. The result was not discussed until a later provider encounter, when GI eval and colonoscopy were recommended, and the resident reported frustration about the delay.
A resident with an ileostomy and tremors was not receiving ordered colostomy assistance. The physician ordered nursing staff to change the appliance and provide colostomy care as needed, but the resident filed a grievance saying staff were not helping empty the bag. A CNA told the resident she should do it herself despite her tremors, and the DON later stated there was confusion about CNA responsibilities for colostomy care.
PHI Left Exposed on Medication Cart: An open laptop on an unattended med cart displayed a resident’s EHR, and multiple papers with residents’ PHI were left visible on top of the cart, including diet orders, med lists, appointment information, physician notes, and personal effects records. Facility leadership stated resident information and computer screens should be secured and not left visible or unattended.
An unlocked med cart on the 300 Hall was left unattended in the hallway and accessible to anyone passing through the area. RN stated he left the cart unlocked, even though it contained narcotic meds in a locked box and other resident meds in the drawers. The UM and DON stated all med carts are expected to remain locked and secured, and that the assigned nurse is responsible for keeping the cart secured.
A resident’s oxygen order lacked a flow rate and delivery device, and three residents using oxygen via nasal cannula were observed with tubing that had no label or date showing when it was changed. Staff confirmed the missing labels, and the DON stated the order and tubing did not meet expectations.
Delay in Obtaining Ordered Narcotic Pain Medication: A resident admitted after multiple amputations reported severe post-op pain and had orders for hydrocodone-acetaminophen and other pain meds. The MAR showed the narcotic was unavailable from the pharmacy overnight and was not administered until the next morning, while staff documented repeated attempts to get the prescription filled and noted the pharmacy did not receive it until the next day.
Two residents did not receive timely follow-through on ordered lab testing. One resident with sepsis risk factors had CMP, CBC, CRP, HgbA1c, and ESR orders, but specimens were not collected until 3 days later; the resident was later found unresponsive, CPR was started, EMS was called, and the resident was pronounced deceased. Another resident with acute kidney failure, CKD, acute respiratory failure with hypoxia, COPD, DM2, HTN, A-fib, PVD, and an unstageable pressure ulcer had ordered potassium, magnesium, CBC, CMP, and CRP testing, and was later transferred to the hospital for edema, AMS, and hypotension. Staff interviews showed they were not aware of the pending labs or monitoring needs, and the MD stated suspected sepsis labs should be obtained the same day or by the following morning.
Unlocked bed wheels were observed for two residents while the beds were in use. One resident with muscle weakness, impaired gait, chronic pain, burns with skin graft, and right foot drop had a fall after the bed shifted, and the resident reported the bed had slid on other occasions because the wheels were unlocked. A CNA stated bed brakes should be relocked after cleaning, an RN stated unlocked wheels could contribute to falls, and the DON stated the beds should be locked at all times when in use.
A resident with depression, dementia, Parkinson's disease, macular degeneration, and anxiety voiced suicidal statements and expressed loneliness and feeling trapped, but the EHR did not show a referral for behavioral health talk therapy. The DON was unaware of the statements, and the NP stated the resident should have been referred for behavioral health services after reporting self-harm thoughts.
Failure to administer ordered IV fluids: A resident with AKI, CKD, and acute respiratory failure had an order for LR 250 mL IV PRN with reassessment after each bolus, but the TAR showed no LR bolus was given as ordered. The resident was later transferred to the ER for edema, AMS, and hypotension, and the NP stated the LR was intended to be given one bolus at a time with reassessment, not as three consecutive boluses.
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