A resident with stroke, dementia, and dysphagia was care planned as needing monitoring for chewing and swallowing problems and was admitted on a CCHO/LCS diet with regular texture. After episodes of coughing and difficulty swallowing meat, SLP evaluated the resident, and a FEES study recommended a minced and moist mechanical soft diet, medications in puree, upright positioning during and after meals, and double-swallow strategies. SLP documentation later described the resident as on a mechanical soft diet with thin liquids and pills crushed in puree, requiring total supervision at meals, but the EMR contained only an ongoing order for a regular-texture CCHO/LCS diet with no documented diet changes. The swallow study was scanned into the EMR under a miscellaneous tab without an alert, there was no documented provider notification or response, and the nurse who reported calling the provider and being told to continue the regular diet did not enter a progress note. Staff interviews showed uncertainty about how SLP recommendations and test results were communicated and processed, and no relevant policy was provided.
A resident with hypotension and intact cognition was started on an antihypotensive medication, with care plan directions to monitor blood pressure and pulse and to assess for side effects and effectiveness. After the resident reported low blood pressure and symptoms of dizziness and lightheadedness, a provider ordered orthostatic blood pressures twice daily for three days, including lying, sitting, and standing measurements, with results to be sent via EMR message. The EMAR showed that on multiple days only single blood pressure readings were documented, required orthostatic positions were missing, and some ordered evening orthostatic sets were not recorded at all, with one complete set documented only in a nurse’s note due to EMR entry issues. Staff interviews confirmed that CNAs usually obtained vitals, nurses later entered them, orthostatic technique varied, and required EMR messages with results could not be located, and no policy on orthostatic blood pressures was provided.
A hospice resident with a history of stroke, depression, anxiety, psychosis, insomnia, and impaired mobility had an established psychotropic regimen including clonazepam, lorazepam (Ativan), and Seroquel to manage terminal agitation and behavioral symptoms. After admission to hospice, an administrative nurse insisted the resident could not receive both clonazepam and Ativan, pressured staff to contact the PCP, and clonazepam was abruptly discontinued without hospice being notified, despite the PCP’s original plan to taper it gradually. Following this change, documentation showed the resident became increasingly agitated, paranoid, confused, and tearful, refused care and medications, attempted unsafe activities such as trying to leave his room and facility, and sustained an unwitnessed fall with a skin tear and low back discomfort, requiring more frequent narcotic pain medication. The resident’s DPOA and hospice staff reported that the resident’s behaviors and anxiety worsened after clonazepam was stopped and that they felt pressured by facility leadership to alter the medication regimen that had previously kept the resident more comfortable.
A resident with dementia, chronic constipation, and orders for daily and PRN laxatives went nine days without a documented BM. During this period, ordered Enulose doses were missed on several days because the resident was sleeping, PRN Milk of Magnesia was never given, and there was no documentation of bowel or abdominal assessments. Staff relied on limited electronic bowel documentation and printed reports, and although a standing bowel protocol and assessment requirements were in place for residents approaching three days without a BM, there was no evidence these were initiated or documented for this resident.
A resident with dementia, severe cognitive impairment, prior left femur fracture, muscle weakness, and total dependence for ADLs was care-planned for transfers requiring two staff and a mechanical lift. Instead, staff transferred the resident using two staff and a gait belt, not in accordance with the documented care plan. The resident was later found with a large, painful bruise on the left chest under the arm, and could not explain how it occurred. Facility documentation and staff interviews confirmed that the EMR Kardex and care plan should guide transfer methods and that nursing is responsible for coordinating resident care, but the ordered mechanical lift was not used during the transfer that preceded the injury.
A resident with intact cognition, depressive disorder, and an antidepressant order requiring monitoring for constipation went six consecutive days without a documented bowel movement, assessment, or treatment. Despite physician orders to follow the bowel routine protocol and PRN orders for prune juice, Milk of Magnesia, and Fleet enemas, staff did not initiate the constipation management steps outlined in the facility policy after three days without a BM. EMR review showed no constipation interventions or progress note assessments during this period, even though nurses reported they receive alerts after three days without a BM and are expected to assess, document, and follow the standing bowel protocol.
A resident with DM and a left foot ulcer had detailed wound care and pneumatic compression pump orders from a wound care consultant, including daily dressing changes with Dakin’s solution and compression pump use two to three times daily. Facility staff documented that the resident returned from wound care with new orders but entered the dressing change frequency in the EMR as only three times weekly and implemented compression pumps once nightly, without a corresponding provider order for that reduced frequency. The resident and the consultant later reported that Dakin’s solution was not being used as ordered, daily dressing changes were not being performed, and the delivered lymphedema pumps were not used as prescribed. Staff interviews confirmed that the daily dressing order was not updated in the EMR, that nurses often had to reach out to obtain wound care orders, and that the facility discovered the pumps only after finding them at the front of the building, resulting in a failure to follow the consultant’s wound care and compression pump orders.
A resident with multiple comorbidities, intact cognition, and total dependence for toileting had PRN orders for polyethylene glycol and bisacodyl suppositories for constipation, with care plan instructions for hospice aides to document bowel movements and notify nursing after three days without a BM. Over a seven‑day period, the EMR showed no documented bowel movement while staff administered ondansetron for nausea and repeated PRN polyethylene glycol doses that were documented as ineffective, yet no bowel or abdominal assessments were recorded in the progress notes. CNAs reported documenting BMs in the EMR, and an LPN described relying on a dashboard alert that only flagged three days without a BM and not reviewing the full bowel record, despite stating that providers should be contacted and daily assessments documented after day four. The administrative nurse expected daily bowel monitoring, use of EMR reports, and documented assessments and notifications, expressed concern about the seven‑day gap without a BM, and confirmed there was no bowel monitoring policy.
Failure to provide ordered foam dressings for a resident with severely contracted hands. A resident with contractures, hemiparesis/hemiplegia, and severe cognitive impairment had a care plan and MD order for Hydrofera blue foam or other foam dressing in both palms and under the nails daily or as tolerated for skin integrity. OT noted skin breakdown on the palms and severe hand contractures, but surveyors observed the resident sitting in a Broda chair with no foam supports in place. An LPN could not explain why the foam was absent, and an admin nurse stated the foam should be placed in both hands daily.
A resident with DM and cognitive impairment was transferred to the hospital with a blood glucose of 31, but the record lacked documentation that glucagon was given before transfer and lacked a progress note describing the event. The facility also failed to document nursing assessments and transfer-related notes for two other residents sent to the hospital, including one resident with a leg laceration requiring 17 sutures and another resident with penile pain and catheter issues. These omissions involved missing assessment and discharge documentation around hospital transfers.
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