A resident with NASH, hepatic encephalopathy, and CKD developed confusion and disorganized thinking, but the nurse did not complete a timely change-of-condition assessment, obtain transfer-time VS, or notify the NP/MD when EMS was called. The resident’s representative reported worsening AMS and pain, while the hospital later documented severe AMS with elevated ammonia. The facility also held ordered rifaximin because it was pending pharmacy delivery/back order, with no doses given and no documentation that the provider was notified that the antibiotic was unavailable.
Delayed Assessment of Change in Condition: A resident with MS, neurogenic bladder, and an indwelling catheter developed cloudy urine, decreased urine output, nausea, and reduced intake, but no timely nursing assessment was documented before EMS transported the resident to the hospital. The resident’s representative reported lethargy and very little urine in the catheter bag, while the LPN documented stable vital signs and said the symptoms could be managed in the facility. Hospital records later showed altered mental status, hypotension, a positive UTI, and suspected sepsis with acute kidney injury.
A resident with diabetes, neuropathy, and hemiplegia had wound care that was not carried out in accordance with orders. Staff observed a right forearm skin tear and a left arm abrasion/wound, but physician orders were not entered into the EMR in a timely manner, and the resident was seen with dated and undated dressings/wraps that were not consistently documented or initialed. Nursing interviews confirmed that new skin issues should trigger physician notification, wound team involvement, and proper documentation, but those steps were not completed as expected.
A resident with dementia and multiple orthopedic injuries was admitted wearing a CAM boot on the right leg after a right ankle ORIF and left hip hemiarthroplasty. The facility documented the boot in the care plan and wound note, but the EMR did not contain physician orders for wearing the boot during transfers or when out of bed, or for skin checks under the boot. Staff interviews confirmed the hospital discharge direction for the boot was not entered into the record, leaving the order unclear to staff.
Delayed response to urinary retention after catheter removal. A resident with severe cognitive impairment and multiple neurologic diagnoses had an indwelling catheter removed and then did not void for hours. The nurse documented that the resident felt unwell and that the bladder scanner was not working, but the MD was not notified at that time. The resident’s representative reported green discharge, penile swelling, and discomfort and requested hospital transfer, but the resident remained in the facility for several more hours before EMS transport. At the hospital, the resident was found to have a distended bladder, suprapubic cramping, green urethral discharge, and 1300 ml drained after catheter placement.
A resident with dementia, malnutrition, and pancytopenia had decreased intake, an unwitnessed fall, and worsening weakness, confusion, pallor, and hypotension, but staff did not notify the provider when the condition declined and monitoring was incomplete before a second unwitnessed fall led to a hip fracture and multiple subdural hematomas. Another resident was found after an unwitnessed fall with a bleeding forehead wound, and staff documented a neuro assessment without properly using a pen light or flashlight to check pupil response.
Failure to Continue and Timely Address Abdominal Wound Care: A resident with DM, CKD, morbid obesity, and dialysis dependence developed an abdominal wound that progressed from a cyst to an open area with slough and drainage. After hospital returns, the existing wound monitoring order was discontinued, new wound care orders were not obtained right away, and the wound was not seen during wound rounds until later. Staff and the wound care physician noted the wound should have been monitored, cleansed, and covered while awaiting assessment.
A resident with paraplegia, muscle weakness, chronic pain syndrome, and other diagnoses had an order for an alternating pressure mattress set at 150 pounds of pressure and checked every shift. Surveyors found the mattress repeatedly set at 350 pounds of pressure while nurses signed the TAR as if it were correctly set and functioning. Staff were unsure of the ordered setting, relied on maintenance or a DME vendor, and the resident reported discomfort and a recent mattress failure that left her on the metal frame.
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.
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