A resident with an indwelling Foley catheter received catheter care for an extended period without a corresponding physician order, and staff confirmed the catheter had been in place continuously while the missing order went unnoticed. Another resident with multiple chronic conditions and bowel/bladder incontinence was hospitalized for nausea and vomiting caused by bowel impaction after the facility failed to include constipation in the care plan and did not complete adequate bowel monitoring.
Late Medication Administration: A resident with anemia, post-amputation orthopedic aftercare, and muscle weakness had several scheduled meds documented well outside the allowed medication pass window, including a PPI, an ARB, and an opioid/APAP. The resident had moderately impaired cognition, the meds were available in the Omnicell, and UMs and the Administrator stated they were unaware of the late administrations and were not auditing med pass times; the facility policy required meds to be given within one hour of the prescribed time.
A resident with multiple contractures and total dependence for ADLs was not receiving restorative care even though OT discharge documentation recommended it after therapy ended. Interviews showed the therapy team did not complete the required restorative referral process, the resident was never added for discussion in morning meetings, and the ADON, CNA, and charge nurse each described gaps in communication and follow-through regarding the resident’s mobility needs.
Insulin protocol and administration errors were identified for two residents with DM and severe cognitive impairment. For one resident, the MAR showed FSBS results below 50 mg/dl, but the MD was not notified as ordered and the recheck results were not documented. For another resident, an LPN did not hold the insulin pen in place long enough after injection, which could prevent the full dose from being delivered.
A resident with a history of hip arthroplasty and related complications experienced increased pain and was found to have a dislocated hip on X-ray. The critical result was faxed to the facility but was not communicated to the physician or addressed by nursing staff until the following day, resulting in a delay in intervention and hospital transfer. Staff interviews confirmed the delay and lack of immediate action as required by facility policy.
A resident with cognitive impairment and a history of falls experienced a right hip fracture after a fall. Despite X-ray findings indicating a possible fracture and ongoing pain, the resident was not transferred to the hospital until the next day due to unclear emergency transfer procedures and delayed provider response, resulting in the need for surgical intervention.
A resident with a PICC line did not receive care according to facility policy and physician orders, including missed and improperly performed dressing changes, lack of chest x-ray confirmation after line insertion, and use of the line without placement verification. Staff interviews and observations revealed inconsistent practices, breaks in sterile technique, and incomplete adherence to enhanced barrier precautions.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive physician-ordered TED hose as required, despite documentation in the MAR indicating otherwise. Observations showed the resident without the compression stockings during required times, and staff interviews revealed that LPNs sometimes documented the task as completed without actually applying the hose, with one LPN unaware of the order. The DON confirmed that documentation should reflect real-time care provided.
A resident with a history of coronary angioplasty and moderate cognitive impairment did not receive daily wound care as ordered by the physician. Staff changed the resident's right-hand dressing less frequently than prescribed, with one bandage remaining in place for several days. The LPN responsible was unaware of the daily order, and the Wound Care Nurse was on vacation, leading to a lapse in following the physician's instructions.
A resident with multiple psychiatric diagnoses did not receive a prescribed antipsychotic medication for over a month because the medication order was not filled by the pharmacy and staff failed to identify or communicate the omission. The issue was only discovered during a medication review with the family, revealing a lack of effective procedures for ordering and tracking new medications.
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