A resident with Type 1 DM had ordered scheduled and sliding-scale insulin, along with instructions to notify the MD for blood glucose readings below 65 mg/dL or above 400 mg/dL. The MAR showed elevated blood glucose results that met the notification threshold, but there was no documentation that the provider was notified. The record also showed a missed scheduled insulin dose and a missed sliding-scale dose, with no documentation explaining why the insulin was not administered. Interviews with the CNA, RN, LPN, and DON confirmed the importance of following physician orders, documenting blood glucose results, and notifying the provider for abnormal readings.
PRN Pain Medication Given Outside Ordered Pain Parameters: A resident with cellulitis of both lower extremities and pain related to infection received Hydromorphone outside the physician-ordered pain range. The MAR showed multiple doses were administered when the documented pain score was below the ordered 6-10 parameter, including several times when pain was 0. An LPN and the DON stated pain meds should be given only within ordered parameters and after appropriate pain assessment.
Failure to Document and Address a Resident Fall: A resident with a hx of repeated falls, impaired mobility, and moderate fall risk had an assisted sit to the floor while being ambulated to the shower room. Although the provider documented the event and later back pain, the record lacked nursing documentation, post-fall assessments, care plan revision, and related progress notes. The DON and NP both confirmed the fall occurred and stated the chart did not contain the expected fall documentation.
A resident with DM, HTN, and ESRD on HD had physician orders for insulin glargine to be held if BG was below 110 and isosorbide mononitrate ER to be held if systolic BP was below 110. MAR review showed multiple administrations of both medications despite readings below the ordered hold parameters. An RN and the DON both confirmed the orders were not followed.
Medication Administration Outside Ordered Pain Parameters: The facility failed to administer pain medications according to provider orders for two residents. One resident received Oxycodone and Acetaminophen outside the ordered pain-scale parameters, and another resident received Dilaudid for pain ratings below the prescribed threshold. Nursing staff stated that giving medications outside ordered parameters is a medication error, and the record contained no documentation or provider authorization for the out-of-parameter doses.
A resident with hemiplegia, weakness, gait impairment, and a contracted hand had active PT and OT eval-and-treat orders, but OT was never completed. The resident was observed in bed with the left hand tightly contracted and reported not receiving therapy for an unknown period of time, while chart review showed no OT services and no care plan update for the ordered OT. The DOR, PT, and DON all confirmed the OT order was not carried out and that communication between nursing and therapy was lacking.
Failure to Monitor and Document a Right Foot Wound: A resident with dementia, DM, PVD, and diabetic neuropathy had a monitored corn on the right pinky toe, but the record later showed an undocumented right foot wound with drainage, pain, and peeling skin. Staff found an old saturated dressing and later observed active larvae in the wound bed. Interviews showed staff were unsure when the wound began, and the DON stated new wounds should be documented and reported.
A resident with dementia, chronic pain, and other significant diagnoses had PRN Morphine ordered for pain rated 4-10/10 or SOB, but staff administered the opioid when the documented pain level was 0 on multiple occasions and failed to give it when pain levels of 4 or 5 were recorded on other occasions. An RN and the DON both acknowledged the inconsistency and stated that PRN pain meds were to be administered according to the physician’s order and pain scale parameters.
PRN pain medications were administered outside ordered pain-score parameters for two residents. One resident with psychiatric diagnoses received oxycodone-acetaminophen when documented pain was below the ordered 6 to 10 range, and another resident with dysphagia, GERD, HTN, and anxiety received oxycodone HCl when documented pain was above the ordered 4 to 6 range. LPNs and the DON confirmed the MAR entries did not match the physician orders, and the facility policy required medications to be given in accordance with prescriber orders.
A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
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