A resident with dementia, severe cognitive impairment, limited ROM in both LEs, and dependence on staff for wheelchair locomotion was observed sitting in her wheelchair with her feet hovering above the footrests. CNAs confirmed her feet did not reach the footrests, and an administrative nurse stated the footrest needed to be adjusted to better fit and support her feet.
A resident with multiple chronic conditions, including lymphedema, HF, DM, and depression, had a physician order for ace wraps to both lower legs every Wednesday and Saturday. Records and observations showed the wraps were not consistently applied, the resident was repeatedly seen with swollen legs and no wraps in place, and staff reported the treatment was only completed part of the time. The resident stated the wraps were hit or miss and said she felt depressed and frustrated because the help she needed was not being provided.
A resident with dementia, dysphagia, CKD, and influenza had a documented decline in intake and respiratory status, but meal percentages were inconsistently recorded and intake monitoring during the acute change was not adequately documented. In a separate issue, another resident with severe cognitive impairment had multiple purple bruises and a skin tear, yet weekly skin documentation did not capture the bruising, and ordered protective interventions such as a floor mat and arm sleeves were not consistently in place.
An LN failed to follow a physician’s wound care order for a resident with a surgical left foot wound, osteomyelitis, DM, and other chronic conditions. Instead of cleansing the incision and applying Aquacel AG over the staples as ordered, the nurse used [NAME] Collagen because the ordered dressing was not available. The DON-level nurse stated staff were expected to follow the physician’s treatment order and obtain a new order if the ordered dressing was unavailable.
A resident with severe cognitive impairment, total ADL dependence, and seborrheic dermatitis did not receive ordered topical treatment for his face and scalp. Hospital discharge instructions and facility orders included ketoconazole shampoo, ketoconazole cream, and Vanicream/A&D ointment, but MAR/TAR review showed no documentation that these treatments were given. Facility notes repeatedly described the skin as normal, while later hospital readmission documented a significantly worse fungal facial rash with reddened, flaky areas on the face and ear; staff interviews confirmed skin concerns had been noticed and reported.
A resident with severe cognitive impairment, total ADL dependence, and fragile skin sustained repeated bruises, abrasions, and skin tears during transfers and personal care. The injuries were documented as occurring when her arm or hand rubbed against a lift sling, wheelchair armrest, or staff clothing, and when she struck her toe on the lift. Staff repeatedly provided education after each event, while the resident continued to have healing skin tears and wore Geri sleeves for protection.
Failure to Monitor and Respond to Prolonged Absence of Bowel Movements: A resident with constipation, dementia, severe cognitive impairment, and bowel/bladder incontinence had no documented BM for 13 consecutive days. The record lacked documentation of bowel monitoring, progress note follow-up, or administration of ordered PRN constipation meds, despite staff stating they used a 3-day no-BM list and would give MOM or a suppository. The facility policy also lacked monitoring and follow-up after 72 hours without a BM.
Failure to Apply Ordered Ace Wraps for Dependent Edema: A resident with edema, CHF, and daily diuretic use was ordered Ace wraps for his legs, but staff did not consistently apply them and sometimes charted them as applied when they were not. Surveyors observed the resident without the wraps on multiple occasions, and the resident said the wraps rarely happened unless he reminded staff. An LPN acknowledged the inaccurate charting, and an Administrative Nurse stated refusals should be documented instead of recording application when the wraps were not on.
A resident with PVD, osteomyelitis, and recent toe amputations had ordered wound vac therapy for a right foot surgical wound. An LPN placed Aquacel AG under the wound vac despite the TAR, and the wound care clinic later found the dressing had clogged the vac, the wound had worsened with more necrosis and pain, and the resident was sent to the ED for further evaluation. The nurse said there were conflicting orders and she did not verify the correct one.
Failure to Follow Transfer Care Plan and Respond to Change in Condition: A resident with hypotension, dementia, DM2, CKD, and HTN was supposed to be transferred with a full-body mechanical lift, but staff used a sit-to-stand lift instead and the resident passed out. The nurse documented initial VS and brief assessment findings, but the chart lacked follow-up documentation, and staff stated they had stopped calling the MD when the episodes occurred even though the event was a change in condition.
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