Failure to carry out ordered blood glucose monitoring: A resident with type 2 DM, hypoglycemia, and severe cognitive impairment had an MD order for AM blood glucose checks with notification if results were above 250, but the order did not appear on the June MAR. An LPN stated orders were entered into the electronic record and should flow to the MAR, while the DON confirmed the order was in the order summary but not on the MAR and stated staff were expected to enter orders correctly and ensure they were carried out.
A resident with DM and intact cognition was using a blood sugar sensor device, but the order was not documented on the physician orders or MAR. Staff observed the sensor patch on the resident’s arm, and LPNs said the resident’s blood sugars were checked through the device and the patch was changed every 10 days. Pharmacy records confirmed repeated fills, while the DON and Medical Director acknowledged the device should have been reflected in the physician orders.
A resident with COPD and moderate cognitive impairment was not provided oxygen equipment care per orders, and a nebulizer treatment was given while the nurse left the room. The resident was not care planned to self-administer medications, yet staff did not remain present during the inhaled treatment, and the oxygen tubing and humidifier bottle were observed dated beyond the ordered change interval. The RN stated she did not check the humidifier water daily and changed tubing monthly, while the DON stated the nurse should stay in the room during the treatment and follow the ordered oxygen care schedule.
A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
A resident with COPD and a UTI had two antibiotics ordered, but one was not given during med pass and one was missing from the med cart. The antibiotics were delivered and signed for by an LPN, then left in the overflow box for several days before administration began. The RN supervisor entered the order duration without verifying it, and the actual directions were different from what was entered in the EHR.
A resident with COPD, anxiety disorder, malnutrition, and a history of alcohol abuse in remission, who was receiving benzodiazepine anti‑anxiety medication and had no order or care plan allowance for alcohol, was found multiple times to have consumed alcohol in the facility. CNAs and LPNs discovered empty and full alcohol bottles in the resident’s room and observed the resident appearing drunk, groggy, confused, lethargic, and slurring words, with noted balance and behavioral changes. The APRN documented increased drowsiness, equilibrium concerns, and later confusion and auditory disturbances, and held the anti‑anxiety medication after learning of intoxication. The DON and Administrator reported that the resident identified a CNA as the source of the alcohol, and the CNA admitted to bringing alcohol to the resident on two occasions, resulting in intoxication within the facility, contrary to the resident’s orders and care plan.
Surveyors found that the facility failed to follow physician orders for PICC line dressing changes, wound care, and catheter care for two residents. One resident with osteomyelitis, pressure ulcers, and an indwelling catheter had multiple missing entries on the TAR for ordered PICC line dressing changes, daily pressure ulcer treatments to the heel and coccyx, and catheter care every shift, with the DON confirming that blank TAR blocks indicated treatments were not completed. Another resident with a PICC line for antibiotic therapy had an order for weekly dressing changes, but the dressing was not changed as scheduled, the PICC site was left uncovered for several minutes during medication administration, and an LPN admitted initialing the TAR to indicate a dressing change that she had not performed, while the TN and APN confirmed the order required adherence to the weekly schedule.
Missing Physician Order for Oxygen Therapy: A resident with COPD and other significant respiratory diagnoses was observed receiving oxygen via nasal cannula, but the EHR contained no physician's order for oxygen therapy. An LPN confirmed the oxygen was in use and could not locate an order, and the APRN, MDS Coordinator, DON, and Administrator all acknowledged that an order should have been in place. The facility policy also required verification of a physician's order before oxygen administration.
Undocumented Dressing and Wound With Maggots Not Reported
Two residents with significant cognitive and neuromuscular/orthopedic conditions experienced falls when staff did not follow care-planned assistance and supervision requirements. One resident, care-planned for two-person assist with bed mobility, transfers, and personal hygiene, was found on the floor after a CNA attempted incontinent care alone. Another resident, care-planned for staff assistance with dressing and two-person assist for transfers with a slide board, was left seated at the edge of the bed and told to dress themself; the resident fell while unattended and was later found on the floor wearing a C-collar. CNAs reported relying on the electronic care plan/Kardex for instructions, but one CNA described unclear and brief initial training on accessing the system, while leadership stated CNAs were expected to verify care needs in the electronic care plan before each care episode.
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