Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
A facility failed to follow professional standards for bowel care for four residents with diagnoses including PLS, diabetes, cervical fracture, COPD, sepsis, MI, and interstitial pulmonary disease. Chart review showed extended periods without documented BMs and no nursing documentation of intervention despite physician orders for bisacodyl, suppositories, Fleet enemas, senna-docusate, and PEG 3350. The DON stated the required nurse intervention documentation was missing.
Medication Administered Outside BP Parameters: A resident with HTN, chronic respiratory failure with hypoxia and hypercapnia, and a recent fracture had an order for Losartan 50 mg with hold parameters for low SBP/DBP. The MAR showed BP readings below parameter on multiple days, yet the medication was still given on several occasions despite the order to hold it.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
PEG Tube Flush and Med Admin Orders Not Followed: A resident with a PEG tube, cerebral palsy, and dysphagia had physician orders for specific enteral flushes and bolus feeds. An RN was observed leaving the feeding bag connected after the feed was empty, then administering crushed meds one at a time through the PEG with water and flushing with more than the ordered amount between meds; the RN could not state how much water was used, and the DON said the RN did not follow the physician's flush orders.
Failure to follow orders affected multiple residents. Several residents with constipation had bowel flowsheets showing 4 to 8 days without a BM, but there was no documentation of ordered BM meds or other nursing interventions. One resident also reported CPAP problems, yet the record lacked an active CPAP order and the care plan did not address CPAP use. Another resident had repeated low BP readings below the ordered threshold without documented cardiology notification.
Multiple residents did not receive care according to physician orders and care plans. One resident with complex medical and psychiatric conditions had an ordered weekly skin assessment missed, and later was found with a widespread red, moist, painful rash that the representative had been treating independently with Nystatin powder, which was not on the MAR. Another resident on Sertraline for depression had required every-shift behavior and side-effect monitoring incompletely documented over several months, and multiple doses of the antidepressant were not administered as ordered. A third resident on antipsychotic and antidepressant therapy had required every-shift behavior and side-effect monitoring that was frequently not recorded. Additionally, a resident with Parkinson’s disease and diabetes went five days without a bowel movement, and the ordered stepwise bowel protocol, including PRN laxatives and enemas after three days without a BM, was not implemented.
Two residents did not receive care according to physician orders and professional standards. One resident with a history of fracture and schizophrenia had albuterol and fluticasone inhalers kept at the bedside, which staff reportedly allowed due to delays in reaching the room, despite no physician order or self-administration assessment documented in the record. Another resident with a blood clot and depression was found with ordered Sage boots off and placed on a chair, even though the medical record required bilateral use at all times with refusals documented, and there was no record of refusal on the day observed; both an LPN and the DON acknowledged the boots should have been in use.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
A resident with type 1 DM, partial left-side paralysis, and ataxia after a stroke was observed with glucose tablets on his desk and reported taking them whenever he felt his blood sugar going low. A physician note referenced the resident taking glucose tablets when blood sugars were in the 60s, but a review of current physician orders showed no active order for glucose tablets, which was confirmed by the CRN and DON.
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