A facility failed to obtain and implement physician orders that matched residents’ care plans and assessed needs. Two residents with significant ROM limitations and dependence for bed mobility had care plans directing turning and repositioning every 2 hours, but the corresponding physician orders were missing, and one resident’s documentation system no longer reflected the intervention. In addition, a resident with a chronic suprapubic catheter had catheter care orders, but the orders did not include the clinical indication for the catheter.
A resident’s newly admitted medication orders were not entered as STAT, and several scheduled meds were not available at the time they were due. The resident complained of pain and was told by an LPN that the pain med was unavailable until the next shift; another nurse later contacted pharmacy and obtained the medication for administration. The DON stated the expectation was to enter newly admitted residents’ medication orders as STAT so pharmacy could deliver them within four hours.
A resident with dehydration and low blood pressure did not receive ordered IV fluids until the next day, and the unit crash cart was missing IV supplies needed to start the infusion. In a separate event, an ADON performed wound care for a resident with a venous/arterial ulcer but used an abdominal pad instead of the ordered border gauze. Interviews showed staff could not locate the IV starter kit when needed, and the ADON acknowledged not reading the wound order personally.
A resident receiving tube feeding was found with the formula bottle empty at the bedside and no label showing the date, time, or infusion rate. Pump history showed the resident had received far less than the ordered amount, and the physician order did not include specific start or stop times. An LPN said the pump was already off at the start of the shift and needed to review the order to know when to run the feeding, while the DON confirmed the feeding was not labeled correctly and the order was incomplete.
A resident’s scheduled morning meds were delayed until late afternoon, and two scheduled Tylenol 650 mg doses were documented as given within three minutes of each other. The MAR showed the resident received 1,300 mg of acetaminophen as a single administration, and the DON confirmed the doses were given concurrently and exceeded the safe single dose.
Failure to ensure call bell access, report a fall, and administer meds on time. A resident stated he/she slid from a wheelchair while reaching for a call bell that was out of reach, and the fall was not documented or reported in the chart. In a separate complaint, a resident's MAR showed multiple meds for DM, CHF, HIV/AIDS, pain, and other conditions were administered late, and the DON stated meds are expected within one hour before or after the due time.
A resident with developmental/intellectual disability and no adequate decision-making capacity had an Assist Bar/Side Rail assessment that was initially documented without risks, benefits, or informed consent being discussed. Later, the EHR was changed to show those items were completed, while the effective date/time still reflected the admission evening, and the paper chart showed consent was actually obtained by phone the next day with the responsible representative. The DON and UM acknowledged the documentation concerns and that the UM was not present at admission when the changes were made.
A resident with an order for a rescue inhaler for SOB and wheezing was observed in distress, but the inhaler was delayed while a CMA stocked the med cart and did not report the request to the nurse. The record showed the inhaler was later documented with a late entry, and there was no nurse assessment before administration, which was not consistent with the DON’s stated practice for PRN meds.
Failure to follow an active turn-and-reposition order was identified for a resident with stage 3 pressure ulcers to the sacrum and buttock. The resident was observed lying on the back multiple times across two days, while the TAR showed the order was signed off as completed on day shift. An LPN stated the nurse and GNA were expected to turn and reposition the resident throughout the shift before signing off the order.
Late Medication Administration and Documentation: A resident’s MAR audit showed multiple scheduled meds were not documented until after midnight, including topical cream, anticoagulant, dementia meds, pain/nerve pain meds, and bowel regimen meds. The NHA stated meds should be given within one hour before or after the due time, and an LPN said she administered the meds on time but documented them late because the unit was busy; she also stated meds should be documented immediately after administration.
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