A nurse handed a Bisacodyl rectal suppository to a CNA, and the CNA administered it to a resident even though medication administration was outside CNA scope and the facility policy allowed only licensed staff to administer medications. The resident had MS, constipation, and morbid obesity, and his bowel care plan indicated bowel management by nursing staff. Interviews confirmed the CNA gave the suppository, a second CNA observed the care, and the nurse acknowledged knowing only licensed staff were qualified to administer medications.
A resident with dementia had an emergent change in condition with vomiting, shaking, facial twitching, and uncontrollable movements, and a physician ordered transfer to the ED. EMS was delayed because staff did not know the elevator access code for the Wanderguard keypad; the code was not found in the unit Resource Binder, an off-duty employee had to be called, and EMS took about 10 minutes to leave the facility.
Failure to Monitor and Document a Worsening TMA Wound: A resident with DM, PVD, and a left TMA had a wound that was not adequately assessed or documented by nursing in progress notes, weekly skin checks, or skilled evaluations. The wound later showed marked enlargement, drainage, odor, redness, swelling, slough, and clinical signs of infection, and the resident was hospitalized for fever and cellulitis. Staff interviews confirmed that wound changes were not being captured and that the deterioration was not identified until the wound physician evaluated the site.
CNA Performed Manual Disimpaction Outside Scope of Practice: A resident with multiple cardiac and chronic conditions reported that a CNA inserted a finger into the rectum to remove stool after the resident felt constipated and said something was stuck. The resident said it was painful, and the DON later stated the CNA admitted doing it and said she thought she was helping, even though the facility’s policy said nurses and CNAs are not to perform manual digital disimpaction.
Failure to implement wound care orders and maintain pressure-relieving mattress: A resident with MASD to the buttocks and significant functional dependence had a wound care consult that changed treatment from A&D ointment to Triad paste and requested a nutrition assessment, but the order was not transcribed into the chart and no nutrition assessment was documented. Surveyors also observed the resident’s pressure-relieving air mattress and pump in place but not functioning, with staff confirming the mattress was deflated until the pump was plugged in.
Failure to Identify and Document Bruise After Resident Fall: A resident with COPD and dementia, who had severe cognitive impairment and needed assistance with ADLs, was found on the floor after a fall. Surveyors later observed a large bruise on the right forehead/temple that staff had not identified or documented in the clinical record, and the nurse stated no one had reported the area to her. The DON said staff were expected to identify and report new bruises, but there was no documentation that the bruise had been recognized.
Failure to implement post-op wound care and monitoring for a resident with a left hip surgical incision. The resident’s hospital discharge instructions for incision care, showering, and infection monitoring were not transcribed into orders, the care plan, the TAR, or the Kardex, and nursing documentation did not accurately describe the incision or include re-admission and weekly skin assessments. The wound was later found to have dehiscence and purulent drainage, and an ortho visit documented a superficial surgical site infection.
Failure to address persistently elevated blood glucose levels: A resident with Type 2 DM and hyperglycemia had repeated blood sugar readings above 300 mg/dL over more than a month while receiving scheduled insulin and a controlled carbohydrate diet. Physician and NP notes did not show the elevated readings were addressed, and the UM, nurse, DON, and physician all stated the high readings were not communicated or acted on as expected.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
A resident with severe cognitive impairment, CKD, gout, failure to thrive, and falls had an arterial heel ulcer and sacral wound with documented pain and edema. Wound provider notes ordered lidocaine gel, LE elevation with gentle Ace wraps, offloading, and pre-medication before wound rounds, but these recommendations were not reflected in the physician orders. Surveyors observed the resident sitting with feet flat and not offloaded, and staff acknowledged the resident had pain during dressing changes and that the wound recommendations had not been entered timely.
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