Failure to Notify Physician of Critical Lab Results and Change in Condition: A resident with CKD, AFib, and anticoagulant therapy had critical low platelet counts, repeated low BP readings, and increasing confusion with hallucinations, but the record lacked documentation that the physician was notified of the STAT lab results or the abnormal vital signs. Family members reported the resident was not acting like himself, and the resident was later sent to the hospital with altered mental status, hypotension, hypothermia, thrombocytopenia, acute metabolic encephalopathy, and sepsis.
Failure to Document Neuro Checks After Unwitnessed Fall: A resident with dementia, HF, and weakness reported falling out of bed and later was found to have an impacted, displaced humerus fracture. The record did not show the required 72-hour post-fall neuro checks or follow-up assessments after the unwitnessed fall, and an LPN and the ED confirmed the documentation was missing.
A facility failed to accurately transcribe hospital discharge orders for two newly admitted residents. One resident with bipolar disorder and other mental health diagnoses did not have all ordered psych meds entered correctly, and the MAR did not match the discharge paperwork; the resident later reported withdrawal symptoms and behavioral outbursts. Another resident with HTN, CKD, dementia, and a pacemaker had discharge orders for antihypertensives and Vitamin D, but the MAR lacked hold parameters and the record lacked BP/HR monitoring documentation.
A resident with severe PAD, DM, and dementia had a right foot wound that was not timely or accurately assessed; nursing notes were inconsistent, the wound nurse did not evaluate it promptly, and the resident later went to the ER with ischemic ulcers and toe discoloration. The facility also failed to follow physician orders for insulin and blood sugar monitoring for three residents, with missed or improperly administered basal, pre-meal, and sliding-scale insulin and incomplete BG checks; the DON acknowledged the orders were not followed.
A resident with multiple chronic conditions and a care plan for skin breakdown risk was transferred to an acute care facility, where a black callous on a toe and purulent drainage from the great toe were identified after the facility had documented no skin concerns. The facility also documented medications late for two residents reviewed for changes in condition, and one resident's MAR showed late documentation nearly every day; an LPN stated medication administration should be documented immediately after giving the medication.
A resident with HTN, CHF, and AFib was seen by an NP for low BP, and new orders were written for daily BP and HR monitoring. Record review showed no documentation of BP or HR monitoring on two days, and no corresponding order was entered in the chart for those days. The DON acknowledged the ordered monitoring was not completed.
The facility failed to document 72-hour monitoring after GDRs for two residents with depression and failed to document an immediate injury assessment after a witnessed fall involving one resident. Records showed sertraline was reduced for one resident and Paxil was discontinued for another, but neither chart contained the required close follow-up documentation. A progress note also documented a witnessed fall and family notification, but no injury assessment was recorded at the time of the fall.
A resident with hemiplegia, MRSA, and uropathy had a newly placed suprapubic catheter with repeated drainage noted at the site, but the chart and MAR lacked surgical wound care orders until after the resident was hospitalized for fever, confusion, and foul-smelling drainage. The ADON stated the wound care orders should have been in place after placement of the catheter and that the nurse should have identified the missing orders and called the hospital for clarification.
A resident with irritant contact dermatitis had a wound NP treatment plan for wound cleanser and Zinc Oxide paste, but there was no physician order for the wound cleanser, the Zinc Oxide was not documented as given on the MAR/TAR, and the wound nurse was unaware of the treatment order. Another resident reported receiving the wrong pills, including two Lasix tablets instead of one, and the chart documented a medication error after an RN dispensed an extra Lasix dose.
A resident with dementia, COPD, depression, anxiety, and HTN received PRN Morphine Sulfate multiple times when the MAR did not show the ordered pain rating of 7 to 10 and did not document SOB before administration. The resident was severely impaired in daily decision making and dependent for most ADLs, and the DON acknowledged the concern during interview.
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