Failure to provide ordered PT services for a resident with TBI and severe cognitive impairment. The resident had repeated specialist recommendations for PT, OT, and ST, including ROM and therapy at max allotted intervals, but the record showed no PT screen, eval, or treatment for more than 6 months after the request was approved by the PA. The Rehab Director acknowledged the resident had not received PT since the prior year, and the Administrator and DON could not provide evidence of the ordered rehab services.
Failure to Protect Residents from Resident-to-Resident Abuse: Two residents were involved in a verbal confrontation in which one resident threatened to kill the other and became aggressive while trying to get closer to the other resident. In a separate incident, another resident was observed in a resident’s room with a hand under the bed sheets touching the resident inappropriately while the resident was in a hospital gown without underwear or a brief.
A resident with colitis and renal dialysis dependence did not receive ordered hydrocortisone enemas after hospital discharge because the medication was not available, and MAR review showed multiple missed doses. The resident reported worsening rectal pain, appeared pale and weak, and was later rehospitalized after hospital records noted a relapse of symptoms that improved once the steroid enemas were started. The facility also missed ordered Veltassa doses after a later discharge despite a critically elevated K+ level, and staff acknowledged the medication was not administered because it had not been delivered by the pharmacy.
A resident with chronic pain and respiratory failure received 10 times the ordered Morphine dose after a new concentrated formulation was dispensed and administered without proper reconciliation or transcription into the MAR. Facility nurses did not promptly notify the provider, and the NP who changed the order did not directly communicate the discontinuation of the prior Morphine order to the facility. The report also cites a deficiency involving insulin use for another resident.
A resident with dementia and osteoarthritis had an order for Morphine Sulfate solution, but MAR review showed it was not administered. Surveyors found the opened narcotic bottle was missing 1 mL without documentation of administration, and staff reported the discrepancy was adjusted in the narcotic count after an LPN noticed the bottle had been opened. The Unit Manager did not notify the Administrator or DON, and the DNS said the concern was not brought to her attention until surveyors identified it.
A resident with dysphagia, protein-calorie malnutrition, ESRD, and a feeding tube did not receive multiple ordered bolus Nepro feedings as scheduled. The MAR lacked documentation for several prescribed feedings, the resident reported staff were not consistently giving the tube feedings and sometimes missed them entirely, and the dietitian and DON could not provide evidence that the ordered feedings were administered.
A resident with PTSD, dementia, depression, anxiety, and bipolar disorder had a care plan noting the need to avoid flashbacks and identify triggers, but the comprehensive care plan did not list triggers or interventions to reduce re-traumatization. The record also lacked evidence of a trauma-informed care assessment after the trauma history was identified. The SW acknowledged she did not complete the assessment and was unsure how to do so, and the DON could not provide evidence that the assessment or care plan update had been completed.
A resident with chronic pain and respiratory failure received a 10-fold overdose of Morphine after an NP changed the concentration but did not communicate the discontinued order or new dose directly to facility nursing staff. The MAR did not reflect the order change, the narcotic book showed the incorrect dose was given, and the overdose was not promptly reported or assessed before the resident was later sent to the hospital.
Care plans were not revised by the IDT after resident-to-resident incidents for multiple residents with dementia and related behavioral diagnoses. Records showed that after aggressive or assaultive events involving residents as victims and aggressors, the care plans were updated to note the incidents but did not include new interventions, and both an LPN and the DON acknowledged the omissions.
Failure to Follow Ordered Behavior Monitoring: Two residents, including one with Alzheimer's disease and anxiety disorder and another with dementia with agitation, had physician orders for every-shift monitoring of mood, behavior, and agitation with documentation of the number of occurrences and interventions used. Review of the MARs and records did not show the required documentation, and the DON could not provide evidence that the ordered monitoring had been completed.
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Citations used to create this checklist
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