Two residents did not receive care according to physician orders and professional standards. One resident with a lower extremity venous/arterial ulcer and lymphedema had wound care performed by the ADON and an RN without use of ordered skin prep to the peri-wound area and without application of ABD pads, even though the existing dressing removed from the leg included heavily saturated ABD pads and the CPO specified Dakin’s, skin prep, silver sulfadiazine, adaptic, ABD, and Kerlix every shift. Another resident with chronic pain syndrome, cervical spinal stenosis, and alcoholic polyneuropathy, who was cognitively intact and independent with ADLs, had a standing order for morphine ER 30 mg TID but had multiple scheduled doses not administered when the facility ran out of the medication and did not have the ordered dose available; MAR review and staff interviews confirmed missed doses and lack of timely availability of the prescribed morphine.
The facility failed to follow its alcohol policy by serving alcoholic beverages during a weekly happy hour without physician orders for two residents. One resident with multiple sclerosis, hypertension, osteoarthritis, and depression, who was cognitively intact and required extensive ADL assistance, reported drinking alcohol at happy hour, had signed a form allowing alcohol if the MD agreed, but had no corresponding order or care plan focus for alcohol use. Another resident with chronic respiratory failure, hypertension, mild dementia, depression, and a documented history of alcohol abuse in remission also reported weekly alcohol use at happy hour, had consented to alcohol on admission forms, and had a psychosocial care plan noting alcohol dependency history, yet had no MD order authorizing alcohol. Staff, including the AD and SSD, confirmed that residents were offered up to two alcoholic drinks based on preference, that no list of authorized residents was maintained, and that alcohol consumption was not tracked, despite policies requiring MD orders and pharmacist review for alcohol administration.
A resident with urinary retention had PVR monitoring ordered every 6 hours after Foley removal, but the MAR showed inconsistent checks, missing documentation, and no monitoring on one day. Another resident had a dressing on the forearm without a physician order in place at the time it was observed. A third resident with toe abrasions and a heel pressure injury did not receive ordered wound care consistently, and observations showed heels resting on a pillow instead of being floated and moon boots not being worn in bed.
A resident with a history of falls, fractures, and significant mobility impairment experienced an unwitnessed fall from bed, which had been left in a high position despite care-plan interventions requiring it to be kept low with a fall mat. An RN found the resident on the floor, initiated neuro checks, and documented elevated BP readings and pain but did not complete or document a thorough head-to-toe assessment before moving the resident back to bed, and did not promptly notify the MD, hospice, or the resident’s representative. Hospice was contacted several hours later due to rising BP and severe pain; a hospice RN then assessed the resident, notified the on-call MD, and obtained an order to transfer the resident to the hospital, where imaging revealed multiple fractures and a scalp contusion. Staff interviews and facility policy confirmed that standard practice required immediate RN assessment prior to moving a fallen resident, timely MD and family notification, and adherence to fall-prevention interventions, all of which were not followed in this case.
Missed Blood Sugar Monitoring and Failure to Notify Physician of High Glucose: Staff failed to consistently check a resident’s blood glucose as ordered and did not notify the physician when a reading was above the ordered threshold. The resident had diabetes with ketoacidosis and CKD, was cognitively intact, and had several missed or undocumented blood sugar checks. Staff also documented the resident as unavailable or refusing without further explanation, and there was no documentation that the physician was notified of the elevated glucose result.
Failure to Enter and Follow Post-Orthopedic Dressing Orders: A resident with a right ankle fracture returned from an orthopedic visit with instructions for dressing changes, but the orders were not entered into the EMR and the dressing was not changed as directed. The resident reported the dressing remained unchanged until she alerted staff, and the wound care order was not initiated until later during the survey.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with hemiplegia, dementia, and difficulty expressing pain was injured during a sit-to-stand transfer when her arm became caught in the sling. Staff gave PRN Tylenol and did not notify the representative right away. Bruising and pain were later noted, but the ordered X-ray was delayed until the fracture was confirmed, and a sling recommended for comfort was also delayed.
A resident with type 2 DM used an insulin pump and Dexcom CGM, but the EMR lacked physician orders for the pump, BG monitoring, and pump oversight. The resident said staff did not review her BG readings and she was repeatedly served regular meals instead of the carbohydrate-controlled diet listed on the hospital discharge record. Surveyors observed non-carb-controlled meals and found no documentation that the missing orders had been obtained before the issue was identified.
The facility failed to follow orders for two residents. One resident with severe cognitive impairment had a midline catheter dressing left unchanged beyond the expected interval, and the order for dressing changes was not entered until after the catheter had already been in place for days. Another resident with dementia and diabetes had repeated blood glucose readings in the range for ordered sliding scale Lispro, but the MAR showed no doses were administered and staff did not clarify the order despite multiple elevated readings.
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