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 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.
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.
A resident with MRSA, chronic venous insufficiency, and left lower extremity vascular ulcers did not receive ordered wound treatment after returning from the hospital. The discharge summary directed specific LLE wound care, but the admission orders and TAR did not include the treatment for about a week. Staff interviews confirmed the wound order was missed during admission and that the required review/audit process was not completed.
The facility failed to implement wound care orders for a resident with right heel and ankle wounds, including delayed and missing treatment orders after Wound Provider recommendations, and also failed to maintain bowel regimen orders and documentation for another resident with constipation complaints. The bowel issue involved a consult recommendation to start a bowel regimen, but no corresponding orders were in place, and a suppository was later given without an order or documentation. The DON and PA both acknowledged gaps in the wound and bowel order process.
Delayed Implementation of Wound Treatment Order: A resident with dementia and total ADL dependence sustained a skin tear to the hip, and the wound physician ordered hydrogel plus dressing changes for the wound. Staff interviews showed the nurse rounding with the wound physician was responsible for entering treatment recommendations into the EHR, but the hydrogel order was not started until 9 days after it was recommended.
A resident with multiple comorbidities and a surgical wound after left knee surgery missed the orthopedic follow-up for suture removal, and the sutures remained in place until the resident was finally seen later. Staff interviews confirmed the follow-up was missed multiple times, the original dressing remained in place, and the resident’s record still contained dressing orders even after the ortho visit documented that the sutures had been removed.
A resident admitted for subacute care with multiple diagnoses, including UTI and diabetes, had physician progress notes documenting plans for a repeat UA/CS and initiation of low-dose Lantus insulin, but these intended orders were never transcribed into the electronic physician order system or reflected on the MAR. Review of the record showed no active orders or administration for the repeat UA/CS or Lantus, and no nursing documentation of contacting the physician to clarify the progress note entries. Interviews with the physician, unit manager, nursing supervisor, and DON confirmed that the physician typically enters orders directly into PCC or gives verbal orders to nursing, that the physician likely missed entering these specific orders, and that leadership was unaware that the intended treatments documented in the progress notes had not been converted into active orders or carried out.
Failure to identify and monitor a skin alteration: A resident with CHF, morbid obesity, muscle weakness, and venous insufficiency had intact cognition but was dependent on staff for ADLs and at risk for skin breakdown. Staff observed scab-like areas, dry patches, and a small open area on the lower leg, yet the skin check did not identify the change and the record lacked documented treatment or a monitoring plan. CNA staff said the areas were present the day before and nursing staff were aware, while the UM said she was not aware until informed by the CNA.
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