A resident with significant mobility dependence and intact cognition developed bilateral buttock/coccyx friction injuries during routine care. The care plan identified risk for skin breakdown and directed staff to avoid shearing during positioning, turning, and transfers, but the resident later had partial-thickness friction/shearing wounds with purple, red areas and blood blister-like findings. Staff and the DON believed the injury occurred during brief removal, sheet handling, or pulling the resident up in bed.
Unclarified nephrostomy site care order: A resident with bilateral nephrostomy tubes, quadriplegia, and respiratory failure had a physician order for site care that was not routinely scheduled and had no discontinue date noted. Staff reported they provided dressing changes only when the dressings were soiled or no longer secured, while the resident stated the doctor had instructed that the dressings be changed when soiled or loose. An RN stated the order should have been clarified.
A resident with an indwelling catheter had a Foley placed with the wrong balloon size because the ordered catheter was not available, and CT results later showed the balloon was improperly inflated. In separate findings, an LPN gave a resident Breyna inhaler without offering mouth rinsing as ordered, and hydralazine administration for another resident was documented without required BP readings or clear reasons for doses given or held. The DON stated she was unaware of the catheter issue and could not find documentation supporting the hydralazine administration decisions.
An LPN administered insulin glargine to a resident with diabetes mellitus without priming the insulin pen needle before the injection. The LPN stated she did not prime insulin pen needles before administration, and the DON later indicated staff should prime the insulin pen before use. Facility and manufacturer instructions both stated the pen must be primed before each injection.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
An LPN administered a resident’s scheduled IV Cefepime after the ordered time, despite the facility policy requiring medications to be given within one hour of the prescribed time. The resident, who was cognitively intact and receiving treatment for a surgical site infection, stated staff were often late starting her IV antibiotics, and the MAR showed the dose was charted late.
Improper Insulin Pen Administration: An LPN administered insulin glargine to a resident with diabetes mellitus without priming the insulin pen first. The resident had an order for 32 units SQ twice daily, and the insulin pen instructions stated the pen should be primed with 2 units before each injection.
A resident with urinary retention and an indwelling catheter had catheter care provided while a size 22 Fr catheter was in place, even though the physician’s order specified a size 20 Fr catheter. An LPN reviewed the order, confirmed the mismatch, and stated the needed catheter size was not available in facility supplies.
Failure to follow physician orders was identified for residents receiving insulin and BP medication. A resident with diabetes had low blood sugars documented without the ordered re-checks, and an LPN was observed priming insulin pens in a way that did not match the facility’s policy. A resident with HTN also received hydralazine on multiple occasions even though the systolic BP was below the ordered hold parameter.
A resident with Alzheimer’s disease and depression exhibited intermittent delusional statements, refusals of medications and care, and occasional yelling or suspiciousness toward staff over several months. Nursing notes documented these behaviors but did not show a comprehensive psychiatric assessment or evidence of a sustained major mood episode. A psychiatric NP subsequently added diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel, despite no prior history of schizoaffective disorder and no detailed evaluation in the record to support the new diagnosis. The resident’s representative reported no known mental health history or hospitalizations and was unaware of the schizoaffective disorder diagnosis, and the DON indicated there was no specific facility policy for schizoaffective disorder.
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