An RN failed to complete ordered treatments for seven residents and documented some as done when they were not. The concerns were identified after staff observed the RN inattentive at the nurses station and on a personal cellphone, and camera review showed she spent much of the shift seated and did not enter every room for residents with treatment orders. Affected residents included people with intact and moderately impaired cognition, and the missed care involved dressings, topical creams and powders, wound care, and incision-site cleansing.
Inaccurate documentation of resident treatments: an RN was observed spending much of her shift at the nurses station and on her personal cellphone while charting treatments as completed that had not been done. Two residents initially reported missed treatments, and further review identified five additional residents whose ordered wound and skin treatments were also not completed despite being documented in the EMR as done. The DON confirmed the inaccurate charting and that the facility expects real-time, accurate documentation.
A resident with dementia and impaired cognition left the facility unsupervised after being seen near the exit door, with no staff nearby. Staff searched for the resident, who was later found by a neighbor and returned via EMS. After the resident reported a fall, staff noted a bruised arm and a knot above the eye, and the resident was sent to the hospital with a hematoma to the R forearm.
A resident with respiratory failure and COPD, whose advance directives and orders indicated Full Code, was found unresponsive by an RN. The RN checked for a pulse, confirmed the resident was gone, but did not start CPR or call EMS; another nurse also assessed the resident, and the resident was pronounced dead shortly after. Family members and the DON stated CPR was not initiated despite the resident’s Full Code status.
Failure to notify the physician and/or pharmacy when meds were unavailable led to missed doses for four residents. A resident with depression, a resident with DM/HTN/HLD, a resident with anemia, and a resident with fibromyalgia, hypothyroidism, DM, depression, and OA all had ordered meds not given because they were not available, on order, or pending pharmacy delivery. The MAR/EMR showed missed doses, but progress notes did not document physician/healthcare provider notification in several cases, and the facility could not provide additional proof of the required notifications.
Failure to Monitor Nebulizer Treatment and Maintain Continuous Oxygen Support A resident with COPD, acute/chronic resp failure, and orders for continuous O2/BiPAP support received a nebulizer tx that the RN started but did not stay to complete. The RN did not verify that O2 and BiPAP were reapplied after the tx, while the CNA stated it was not the CNA’s job to stop the nebulizer or place the BiPAP back on. The resident was later found unresponsive, and records showed missing O2 sat and VS documentation, with the BiPAP device off for a period overnight.
A resident with impaired cognition and significant assistance needs was given an IV that was intended for another resident. Staff later found no order for the resident to have an IV, and the resident was noted to have pain in the right hand/wrist after the line was inserted. Interviews confirmed the IV was placed in the wrong patient, and the intended resident was in another room.
A resident with a G-tube, Foley catheter, oxygen needs, malnutrition, and a stage 2 sacral pressure ulcer was discharged without a safe, orderly plan in place. The record showed missing discharge documentation, no confirmed home health or DME arrangements, and no documented tube-feeding, wound-care, or Foley-supply education. The resident reported receiving only a few bottles of tube feeding, having no pump or supplies, going days without oxygen, and having no wound-care supplies or home health aide support after discharge.
A resident with a stage IV sacral wound and wound vac had repeated gaps in wound vac monitoring, inconsistent documentation, and was often observed supine without positioning devices; the wound clinic found the VAC off with no suction and documented worsening wound conditions. Another resident with impaired mobility and bilateral AKA developed a stage II pressure injury to the buttock while being observed repeatedly in bed on his back without wedges or other offloading devices, despite care plan interventions for frequent repositioning and pressure redistribution.
Insufficient nursing staffing and delayed call light response were identified after residents reported waits of 30 minutes to 2 hours for assistance, including one resident left in the bathroom for 45 minutes and another with a 55-minute wait after activating a call light. The CNA scheduler said staffing was based on a corporate PPD target of 2.85 hours per resident rather than acuity, and records showed multiple weekend shifts with CNA, UM, and RN call-offs or no-shows. Residents also reported staff sitting in the lounge, not responding to lights, and unmet toileting and care needs.
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