A resident with dysphagia, esophageal obstruction, AFib, and other cardiac diagnoses had apixaban ordered by mouth BID, but the MAR documented the drug as U-SA for 17 administrations even though the record had no self-administration assessment, order, or care plan. An LPN, RN MDS Coordinator, DOR, and DON all stated that self-administration required those elements and that they were not present in the chart; facility policy also required IDT and physician determination that self-administration was safe and appropriate.
A resident with Type 2 DM was readmitted without active BG monitoring orders, insulin, oral hypoglycemics, glucagon, or a diabetes care plan. Staff documented only one fingerstick during the stay, which showed critically low BG, and the resident later became hypotensive, bradycardic, and severely hypoxic before being transferred to the hospital. Interviews with the CNA, LPN, RN, and DON confirmed the resident’s diabetes was not being monitored as expected and that the NP’s directive for BG checks before meals and at bedtime was not implemented.
A resident with pain after a fall had x-ray orders for the leg, pelvis, and lumbar spine, but the facility did not fax the order to the x-ray provider until several days later, and the fracture result was not received until after the delay. In a separate case, a resident with dysphagia and aspiration risk had an active no-straw order, but the care plan incorrectly stated he needed a straw, and staff observed him drinking from a cup with a straw despite the order.
Failure to Administer Ordered Medications: A resident with multiple chronic conditions and pain-related diagnoses did not receive several scheduled medications after admission, including bedtime and morning orders, and the MAR showed multiple doses as not administered with no documented reason. The record also showed no evidence that the RN contacted the pharmacy or provider or attempted to use the e-kit, and the resident reported being told the facility did not yet have the physician orders and that she was in pain waiting for her medications.
Failure to Provide Ordered Wound Care Treatments: A resident with third-degree burns and a pressure ulcer had wound care orders for the left buttock and left forearm, but the TAR and progress notes showed no evidence the treatments were provided or documented on multiple days. The skin assessment also noted a right outer forearm burn and a left arm/hand burn, while staff, including two LPNs and the DON, confirmed the ordered wound care was not completed as ordered.
Wheelchair Cushion Order Not Followed: A resident with severe debility, DM2, and high pressure-injury risk had a physician order for a wheelchair cushion, but therapy documentation and observation showed the bariatric wheelchair was used without the cushion and with missing armrest padding. The resident reported significant pain while sitting in the chair, and staff confirmed the cushion was absent and the armrest was exposed metal.
Pain Medication Given Outside Ordered Parameters: A resident with rheumatoid arthritis and intact cognition had an order for Sulindac 200 mg BID for pain rated 1-10, along with routine pain monitoring. Review of the MAR showed the NSAID was given at scheduled times on most days even when pain scores were documented as 0, and staff interviews confirmed the medication was administered outside the ordered parameters. The DON acknowledged the order was not followed, and the resident reported ongoing hand pain and difficulty with daily tasks.
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.
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