A resident with heart and vascular disease was readmitted with orders to stop Clopidogrel and ASA and start Apixaban, but the RN entered the new orders without removing the discontinued meds. The EMR generated interaction alerts for Apixaban with ASA and Clopidogrel, but the RN did not recognize or address them, and the night RN supervisor did not complete the required secondary review of readmission orders. The resident continued receiving Clopidogrel and ASA for several doses, and the MD identified the error as significant.
A resident with a history of heart and vascular disease was readmitted after a hospital stay with orders to stop Clopidogrel and Aspirin and start Apixaban. The readmitting RN entered the new orders but did not remove the discontinued meds or address an EMR alert for drug interactions, and the overnight RN supervisor did not complete the required secondary check. As a result, the resident received Apixaban with Clopidogrel and Aspirin for several doses, then developed dark emesis and rectal bleeding and was sent to the ED.
A resident with dementia, severe cognitive impairment, and wandering behavior left the building after an exit alarm sounded and was later found outside near the solarium. Staff had been aware the resident was wandering overnight and had asked the charge nurse to keep a close eye on the resident, but the resident was last seen in the hallway before being discovered outside. The resident was returned inside with no injuries noted.
A resident with Parkinson's disease did not receive ordered Sinemet after admission because the medication was not transcribed from the hospital W-10 into the EMR and was missed during order verification. Staff later identified the omission after the resident developed worsening stiffness, weakness, and loss of mobility, and the neurologist noted the Parkinson's symptoms had worsened. The DON stated the RN and APRN both missed the order, and the error was not corrected when first identified.
A resident with cardiomyopathy, COPD, DM, and CKD was readmitted after a hospital stay with discharge instructions to start nifedipine ER and stop amlodipine. Instead, both calcium channel blockers were ordered and given together for five days because the W-10 discontinuation order was not followed and the medication reconciliation/order checks were not completed accurately.
Elopement-risk resident exited through unlocked front doors. A resident with schizophrenia, schizoaffective disorder, depression, PTSD, impaired cognition, and a history of removing a wander guard was able to leave when the front doors were opened for a visitor. The receptionist tried to redirect the resident, but the resident became resistive and walked out; staff later found the resident off the property near nearby offices after the resident reported going to a gas station and a church. Interviews and facility documentation indicated the alarm status was unclear and the receptionist did not maintain visual contact with the resident as expected.
Failure to supervise a resident with dementia and known wandering/elopement risk led to the resident leaving a secured unit and being found miles away from the facility. Staff last saw the resident on the 4th-floor unit, but video later showed the resident exiting through a stairwell door that had been accessible with a keypad code, and the facility was not aware of the exit until a family friend reported the resident on a street in a neighboring town. The record also showed hourly rounds were not completed per policy.
Failure to Report Allegation of Neglect: A resident with fractures, total assist needs for toileting and bed mobility, and incontinence reported that a nurse aide was rude, yelled, and left the resident in a soiled brief for hours, with other delays in incontinent care also described by the resident and family. Facility staff treated the concern as a customer service issue, did not complete a report to the state survey agency at the time, and documentation did not show a completed incident report or clear follow-up for the mistreatment allegation.
Failure to Thoroughly Investigate Allegation of Mistreatment: A resident with fractures, total assist needs, and bowel incontinence reported that a nurse aide was rude, yelled, and left the resident in a soiled brief for hours, while family emails described refusal to provide incontinent care and accusations that the resident soiled intentionally for attention. Facility records did not show a completed abuse/neglect investigation, grievance entry, or state report, and leadership later acknowledged the concern should have been handled as an abuse/neglect allegation rather than a personality conflict.
A resident with severe cognitive impairment, dementia, and significant assistance needs had a representative repeatedly request copies of the full medical record, but the facility did not release them. Emails showed ongoing back-and-forth with the Administrator about consent, even though a health care representative document authorized the named individuals to request and receive medical information, and the resident had already been documented as unable to comprehend discharge information.
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