A resident with DM2, acute cystitis, HTN, and severe burns had hypotension and a change in condition, with a BP of 88/51 and later a doctor’s visit that led to ER transfer for low BP. The DON, RN, and NP stated the NP was notified of the low BP and instructed staff to give oral fluids and recheck the BP, but staff did not document the repeat BP or call the NP back with the updated result, and one hypotension episode was not documented as reported.
IV Antibiotic Not Administered as Ordered: A resident admitted with sepsis and endocarditis had an order for IV Ampicillin q4h, but the IV tubing remained clamped and the dose was given 2 hours and 30 minutes late. RN, the UM, and the DON all confirmed the resident did not receive the IV antibiotic as ordered because the clamp was not opened.
A resident with DM2, malnutrition, and no teeth did not receive the ordered controlled carbohydrate diabetic diet. The hospital discharge orders, facility admission summary, and NP notes all indicated a diabetic diet, and the niece requested an easy chew diabetic diet due to chewing difficulty. The RD, DON, and NP stated the resident should have received the ordered therapeutic diet.
Failure to Accurately Assess and Track a Worsening Pressure Ulcer: A resident with MS, dementia, malnutrition, incontinence, and poor mobility had a sacral/coccyx wound that was repeatedly documented with inconsistent descriptions such as abrasion, excoriation, small opening, and pressure ulcer. The wound was not consistently measured, staged, or tracked, and the DON stated the facility did not identify or document the wound’s characteristics before it was later diagnosed as an infected Stage 4 pressure ulcer with exposed bone, purulent drainage, cellulitis, and osteomyelitis.
The facility failed to maintain infection control for multiple residents. A resident with a worsening sacral wound and antibiotic orders was not tracked in the antibiotic stewardship or infection control programs and did not have EBP signage posted. Two other residents with sepsis, a stage 4 PU, ESBL, and E. coli also lacked EBP signs, and staff observed providing high-contact care without PPE.
A resident with MS, dementia, and CKD began hospice care, but the facility did not complete a significant change MDS to reflect the hospice status. The DON confirmed the resident was admitted to hospice and that no significant change MDS was completed.
A resident with hypertensive heart disease with heart failure had an order for diltiazem 120 mg daily, to be held if SBP was below 110, DBP below 60, or HR below 60. Staff administered the medication even though the resident's BP was 127/50 and HR was 52. The DON stated staff did not follow the physician's order and that the medication should not have been given outside the ordered parameters.
Missed Baths and Showers Per Schedule: The facility failed to provide baths/showers for 4 residents who needed ADL assistance and were scheduled for routine bathing. Records and staff interviews showed repeated missed or inconsistent bathing opportunities for residents with conditions including muscle weakness, reduced mobility, amputation, paralysis, and a spinal cord injury. Residents reported not being offered showers as scheduled, and CNAs and the DON acknowledged that the residents were not receiving enough baths/showers per the established schedule.
The facility failed to provide enough nursing staff to meet resident needs, and residents reported missed baths and showers because CNAs and LPNs said staffing was too short. Staff confirmed that showers were often missed, including on weekends, and the DON stated showers should be offered according to the facility schedule. The facility also used a resident’s mother to help with a Hoyer lift transfer even though the resident required two trained staff for transfers, and staff stated family members should not assist with Hoyer lift transfers while the resident remained in the facility.
Misappropriation of Resident Belongings: A resident reported her purse, wallet, and reading glasses missing after a housekeeper was in her room. Her purse was later found in the housekeeper’s trash bin and returned, but her wallet with $20 and her reading glasses were never located. Staff interviews confirmed the housekeeper had the purse on her cart and had brought unauthorized individuals into the facility during her shift.
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