LPNs Assigned Wound Care Without Competency Assessment: Several LPNs were assigned wound care duties for residents even though the facility had not assessed their competencies or provided wound care training. The LPNs stated they had limited or no wound care education or certifications, and some said they did not feel comfortable performing wound care. Leadership confirmed wound care responsibilities had been shifted to floor nurses and that no competency evaluations or training had been provided.
A facility failed to document a change of condition for a resident with repeated low BP and low pulse readings, and failed to document physician notification for another resident’s accucheck of 517 when the order required notification for results over 400. The residents had significant medical histories including dementia, heart disease, COPD, and diabetes, and the ADON confirmed the missing documentation.
A resident with a urinary catheter and diagnoses including retention of urine had an order to monitor urine output. The urine output log showed zero output on multiple shifts over several days, but there was no documentation that CNAs notified nursing staff of the zero urine output, and the DON confirmed the lack of documentation.
CNA Failed to Wear Required PPE for Resident on EBP: A CNA provided personal care to a resident with a PEG tube, wounds, and severe cognitive impairment while wearing gloves but not a gown, despite the resident being on EBP and the care plan requiring gowns and gloves for all personal care. The CNA later confirmed the lapse, and the CNA supervisor confirmed the gown should have been worn.
A resident with diabetes had a sliding scale insulin order for 2 units when blood glucose was 150 to 199, but the MAR showed multiple readings in that range with no insulin administered. The NP and DON confirmed the resident should have received 2 units for those blood sugar results.
A resident with severe cognitive impairment and a wanderguard was allowed to exit after a CNA mistook him for a visitor and did not recognize him as an elopement risk. Another CNA later found him outside near a busy roadway, and multiple staff members stated they were unsure how to identify residents at high risk for elopement.
Unattended Medications Left at Resident Bedside: An LPN left 3 prescription pills in a medication cup on a resident's overbed table, contrary to the facility's medication storage policy requiring secure storage. The resident had COPD, DM, HTN, tremors, intact cognition, and needed assistance with ADLs and mobility. The LPN confirmed the pills were from the night shift and should not have been left unattended, and the DON agreed.
Staff failed to demonstrate competency with insulin pen administration and respiratory equipment cleaning. Three LPNs gave insulin to three residents without priming the insulin pen needle, despite orders for insulin in residents with DM. Staff also cleaned a resident’s non-invasive ventilation mask using wipes, alcohol, and paper towels instead of the facility’s soap-and-water method, and the tubing was not cleaned; one LPN stated she had never received training on cleaning the mask and tubing.
Two residents received Voltaren 1% gel without the dosage ordered by the physician, including one resident with severe cognitive impairment and another with moderate cognitive impairment. In addition, staff did not document notifying the physician of a resident’s edema and incoherent status, did not complete a post-nebulizer assessment, and did not follow the care plan for daily weights and monitoring of breath sounds.
Failure to Administer PRN BP Medication as Ordered: Nursing staff failed to give a resident’s PRN Clonidine HCL for hypertension on multiple occasions when the resident’s diastolic BP was above the ordered parameter. The resident had CHF, AFib, angina, HTN, and moderate cognitive impairment, and both an LPN and the DON confirmed the missed administrations.
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