The facility failed to follow physician and therapy orders for several residents. A resident received insulin even though the blood sugar was below the hold parameter, another resident was observed with a straw despite a no-straw diet order, and eye drops were administered inconsistently with the order. The facility also did not ensure wound dressing orders were entered when wounds were found, and it lacked evidence of ordered I&O monitoring and weekly weights for another resident.
A resident with a history of chronic constipation and right hemicolectomy had no documented BM for 10 days, despite scheduled Miralax and PRN sorbitol orders. The facility did not fully implement the constipation protocol or document provider notification when interventions were ineffective. The resident later transferred to the ED for abdominal pain and constipation and was hospitalized with a 7.9-cm rectal fecal impaction and stercoral colitis requiring disimpaction; the DON acknowledged the lack of documentation that the provider was notified.
A resident with frequent loose stools did not receive ordered PRN antidiarrheal medications as documented in the MAR, and staff confirmed the orders were not followed. During a medical emergency, staff discussed changing the resident’s code status while EMS documented the resident was somnolent, confused, and unreliable, despite a FULL CODE order and POLST for full treatment. The facility also failed to complete neuro checks after unwitnessed falls for another resident, and staff confirmed the assessments were not done.
A resident with constipation had multiple stretches of several days without a BM, but the MAR showed laxatives were given late and, in one instance, at half the ordered dose. The record also lacked evidence that the ordered interventions were provided as written or that the MD/FNP was notified when the resident went 4 or more days without a BM.
A resident’s discharge summary stated that the resident takes brand-name Synthroid, and the family repeatedly reported intolerance to generic levothyroxine and supplied home Synthroid. However, the MAR initially listed generic levothyroxine, pharmacy deliveries of levothyroxine continued, and the record lacked evidence that the discharge order was clarified for about three months. A later TSH was elevated, and the physician then ordered brand-name Synthroid.
A resident with CKD stage 5, hemodialysis dependence, and a Foley catheter was given an antibiotic for a reported UTI even though the facility did not have a valid signed provider order. The EMR showed an unsigned order for sulfamethoxazole-trimethoprim, there was no evidence of a provider evaluation or urine culture before treatment, and staff administered the medication based on paperwork and a prescription that had not been properly obtained in the chart.
A resident with a wound vac had an MD order for dressing changes every 48 hours, but the facility did not complete the scheduled changes on time. The hospital SW reported the facility lacked wound vac supplies and that dressing changes had not been done, and the TAR showed the first documented change was not until several days later, with the expected changes not coded as completed.
The facility failed to follow physician orders for multiple residents. A resident’s insulin was not given when blood glucose values were within ordered parameters, and insulin was also given when it should have been held. Another resident had weight gains that met the provider-notification threshold, but there was no evidence the provider was notified. A third resident received metoprolol despite low BP and/or HR parameters, and a fourth resident’s stump redness was not outlined as ordered to monitor for spread.
A resident with dementia and hospice services was repeatedly observed sitting in the dining room with no meaningful activity, despite a care plan calling for escort to activities, preferred activities, and in-room visits; staff said the resident was usually left there and not routinely checked or brought to activities. Another resident on hospice had physician orders for daily weights and intake monitoring, but the record lacked required weight and intake documentation on multiple shifts. A third resident had an unwitnessed fall with a bruise, but ordered post-fall neuro checks were not completed and the family was not notified.
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
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