Failure to Complete Elopement Risk Evaluation: A resident with dementia, cognitive impairment, and psychiatric diagnoses did not have an elopement risk assessment completed on admission, despite a facility policy requiring it for every resident. The record also lacked a later elopement evaluation after the resident left the facility and was missing for over 2.5 hours before police located the resident at a nearby hotel.
A resident with opioid dependence and diabetes was found unresponsive in bed with agonal respirations, pinpoint pupils, and severe respiratory distress. Staff called 911, but interviews and records did not show that a licensed nurse stayed with the resident until EMS arrived; both the LPN and RN left the room during the emergency. EMS documented low O2 saturation, a GCS of 3, and suspected opioid overdose.
A resident with TIA, prior cerebral infarction, and a BIMS score of 12 went on LOA with family, but the charge nurse did not open the sealed pharmacy bag or review the medications and directions for use with the resident and responsible party before the medications were handed over. The overnight LPN signed for the delivery, relabeled the bag for the resident’s LOA, and the day shift LPN gave it to the responsible party without reconciling the medications; the guardian later reported that another resident’s medication had been included.
A resident with acute respiratory failure, autism, intellectual disability, and severely impaired cognition was sent to an orthopedic appointment on oxygen, but the office was not told the resident needed oxygen and staff later found the tank empty. EMS found the resident with O2 sat at 80% and transported the resident to the hospital. Facility staff gave conflicting accounts about whether a full tank was sent, and no staff member accompanied the resident despite the resident’s inability to manage the oxygen flow.
Medication administration errors were identified for several residents with diabetes, pain, and other chronic conditions. Ordered meds, including insulin, oral diabetes meds, potassium, antipsychotic therapy, protein supplement, and pain medication, were not given on time or were coded as refused, held, or unavailable. An RN stated she was late to the shift, did not notify the DNS/ADNS or supervisor, and did not search the med room or automated supply for missing meds before documenting them as unavailable.
A resident with dementia, schizoaffective disorder, severe cognitive impairment, and a history of aggressive and resident-to-resident altercations was involved in an unwitnessed physical altercation with another resident, resulting in a fall, facial laceration, and a closed fracture. The resident was sent to the hospital for evaluation and then readmitted, but the hospital discharge paperwork did not include the expected psychiatric evaluation or harm clearance. The admitting RN did not obtain psychiatric clearance or a no-harm letter at the time of readmission, and the resident was not evaluated by a psychiatric provider until nearly eight hours later. Facility leadership acknowledged that the readmitting RN was responsible for identifying missing documentation and that there was no specific policy for psychiatric evaluations or 1:1 assignments following physical altercations.
A resident with a history of kidney transplant was readmitted from the hospital with an order for Tacrolimus XR totaling 6 mg daily. During medication reconciliation, an RN used the prior EMR orders and changed the number of tablets from one to six but failed to adjust the tablet strength from 4 mg to 1 mg, creating an EMR order for six 4 mg tablets (24 mg total). The required second reconciliation by another RN was not completed, and an LPN administered the dose as entered, relying on the assumption that two supervisors had verified the orders and that the medication’s presence in the cart indicated correctness. This sequence of transcription error and missed double-check resulted in the resident receiving a fourfold overdose of Tacrolimus.
A resident with CHF, respiratory failure, pulmonary edema, dementia, severe edema, incontinence, and dependence for bed mobility and transfers was repeatedly scored as only mildly at risk for pressure injuries on Braden evaluations completed by an LPN. Therapy and nursing documentation described the resident as bedfast most of the time, incontinent, requiring a mechanical lift or stander with assist of two, and having +3 pitting edema with some open areas, which supported a much lower Braden score and high risk status. The care plan carried over outdated interventions (assist of one for transfers) and did not fully reflect current PT/OT recommendations or the resident’s true functional status. Facility leadership confirmed that Braden tools completed by LPNs were not reviewed or co-signed by an RN, despite state practice standards that LPNs cannot independently perform nursing assessments, and the ADNS later acknowledged that the Braden scores were inaccurate and understated the resident’s risk.
A resident with severe cognitive impairment, multiple psychiatric and medical diagnoses, and dependence for ADLs and transfers fell forward from a wheelchair while an LPN was repositioning the resident, resulting in a forehead laceration requiring sutures. Although the care plan identified fall risk and altered mobility, the facility’s post-fall documentation did not include staff witness statements or a root cause analysis. The DON confirmed that no staff statements or analysis of the cause of the fall were available, despite facility policy requiring written witness documentation and a root cause analysis after witnessed incidents.
A resident with MS, paraplegia, dementia, and depression experienced an acute change in mental status, including word-finding difficulty and dysarthric speech. An LPN notified the supervisor RN, who initially felt the resident was at baseline, but later another LPN confirmed the change in condition. The APRN, contacted via AV technology, identified the situation as an acute, critical problem, agreed with hospital transfer, and documented that EMS had been activated. However, EMS records showed that dispatch was not contacted until 41 minutes after the APRN’s note. When EMS arrived, the resident was obtunded with very low systolic BP, requiring IV fluids and Narcan before transport, demonstrating a delay in timely EMS activation following a significant change in condition.
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