Failure to provide ordered bowel management and wound care: one resident had prolonged constipation with no documented bowel sounds assessment, delayed physician notification, and incomplete bowel documentation; another resident’s ordered wound treatment was not signed out on the TAR; and a third resident had no documented BM for days, no constipation care plan, no physician notification, and a missed PRN suppository order.
A resident with dementia, CKD, AFib, and prior falls had unwitnessed falls that were not followed by complete post-fall documentation or neuro checks, and the record showed inconsistent charting before the resident was later hospitalized with intracranial hemorrhage and an occipital fracture. A second fall was also not promptly documented or fully assessed, and the resident was later found to have a humeral fracture. Two other residents with unwitnessed falls likewise lacked documented neuro assessments.
The facility failed to follow ordered parameters for a resident’s antihypertensive medication and another resident’s insulin, administering both when BP, pulse, or glucose were below hold limits. It also stopped documenting follow-up after a resident’s fall before the required 72 hours were complete. In addition, a resident with dry, scaly, scabbed lower legs had no documentation of assessment or treatment/refusal despite visible skin changes and itching.
A resident with dysphagia, a G-tube, and a history of TBI had orders for enteral feedings, flushes, placement checks, residual documentation, and tubing changes to be completed by licensed nursing staff. However, multiple QMAs documented that they started and stopped tube feedings, flushed the tube, checked placement, and changed the bag and tubing. Interviews showed staff had been instructed under prior leadership that QMAs could perform these tasks, and the QMAs stated their charting reflected care they actually provided.
Failure to document and monitor a resident's worsening skin condition. A resident with ESRD on dialysis, DM2, and chronic vascular disease had bilateral leg cellulitis, edema, and later documented wounds/venous ulcer findings, but the chart lacked consistent progress notes, skin monitoring, and documentation of ordered compression wrap treatments. Staff reported the resident often prioritized smoking, removed dressings when uncomfortable, and refusals or dressing removal were not consistently documented.
Failure to Document and Review Resident Bruising: A resident with dementia was found by a hospice aide to have new bruising on the left forearm after a shower, and the aide reported that the resident identified a facility aide as causing the bruising during a transfer. The ED and DON later observed the bruise, but the clinical record contained no assessment, monitoring, or timely IDT review documentation, despite facility policy requiring bruise incidents to be entered in the EHR and reviewed in wound management.
A resident with cognitive impairment and a Foley catheter had a missed urine collection for worsening confusion, then a later urine culture showed a UTI, but the physician was not clearly notified. The ordered antibiotic was delayed and a later dose was missed, while the resident developed fever, hypoxia, and decreased responsiveness. Nursing notes and provider texts did not clearly communicate that the resident needed hospital transfer, and the resident was ultimately sent out with sepsis, aspiration pneumonia, UTI, and severe dehydration.
Wound treatments were not consistently completed or documented for two residents. One resident with diabetes and a recent toe amputation had missing TAR entries for ordered wound care, reported that foot treatment had not been done for days, and later required emergency surgery for another toe amputation. Another resident with paraplegia and stage 4 pressure ulcers had multiple missing TAR signatures for ordered wound care and wound VAC treatments, while staff stated the wound nurse usually completed the care and others documented it afterward.
A resident with HTN had physician orders for Coreg and Hydralazine to be held when SBP was below 110, but the MAR showed multiple doses were still given when SBP readings were under the ordered parameter. RN 4 stated the physician-set parameters should be followed, and the facility policy said meds are to be administered in accordance with written MD orders.
A resident receiving hospice care with chronic respiratory failure and other diagnoses was ordered hydromorphone for shortness of breath and PRN comfort, but the MAR showed no scheduled or PRN doses were given. The record noted the medication was unavailable or on hold, and the DON stated the facility could not administer the ordered form because the tablets could not be cut as directed and hospice and the physician were not notified that the medication was not available.
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