A resident with intact cognition, high fall risk, and multiple mobility and medical issues developed several days of nausea, vomiting, poor intake, weakness, and decline, but the record showed no timely comprehensive assessment, vital sign monitoring, or provider escalation. Nursing and therapy notes documented ongoing symptoms, meal refusals, and limited treatment with ondansetron, yet there was no clear follow-through before the resident had an unwitnessed fall while trying to vomit in the bathroom and was sent to the hospital with serious injuries and severe metabolic abnormalities.
A resident with ESRD, COPD, renal dialysis dependence, and severe cognitive impairment had physician orders for a CBC, CMP, occult stool test, and nursing assessment for external hemorrhoids and unusual bleeding related to anemia. The EHR showed the ordered labs were not obtained and no nursing assessment was documented, despite LPN/RN job duties that included collecting specimens, performing assessments, and communicating results to the medical team.
Failure to Provide Ordered Meal Tray: A resident with severe cognitive impairment, dysphagia, and PEG tube feeding had an active order for a CCD NAS puree diet with thin liquids and a care plan calling for a pleasure tray and staff assistance with meals. Surveyors observed the resident receiving continuous tube feeding while meal trays were passed on the hall, but the resident did not receive a tray; the CNA and LPN stated the resident did not get meal trays because she was tube-fed, while the DON could not provide documentation of refusal and the Dietary Manager stated trays were ordered.
Incomplete MAR Documentation for PRN Acetaminophen: The facility failed to accurately document PRN acetaminophen administration for two residents. One resident with multiple chronic conditions and a pain-management care plan received Tylenol from an LPN, but there was no MAR entry or progress note documenting the dose. Another resident with CHF, chronic respiratory failure, Parkinson's disease, and a pain-risk care plan had acetaminophen administered, but the MAR was left blank. The DON stated that standing-order medications must be entered into the MAR before administration.
A resident with chronic respiratory failure with hypoxia was observed receiving oxygen at 2 LPM, and the care plan and MDS indicated oxygen therapy was in use. However, review of the physician orders found no order for oxygen therapy, and an LPN and the DON both confirmed the EHR contained no such order.
An LPN provided suprapubic catheter care to a resident with a suprapubic catheter, CKD, recurrent UTIs, and severe cognitive impairment while the resident repeatedly cried out in pain, guarded the area, and had visible bleeding at the site. The nurse continued the procedure, did not stop to assess pain during care, and only asked about pain after finishing. The nurse then gave acetaminophen 650 mg without first confirming a current MAR order and used an older standing order instead of the current PRN pain order.
A resident with severe cognitive impairment, incontinence, and total dependence for toileting had a UA, C&S ordered after staff noted a strong odor to the urine. Staff attempted to obtain the specimen by straight cath, but the wife refused the procedure and also would not allow Foley placement. No lab results were found, and staff stated the refusal was not documented or communicated to the CNP, and the order was not discontinued.
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.
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