Failure to Monitor and Respond to Substance Use and Overdose: The facility did not adequately assess or document care for two residents with substance use concerns. One resident had a drug overdose requiring Narcan, but the record lacked ongoing monitoring such as neuro checks and VS after the event. Another resident with a history of opioid and polysubstance use showed erratic behavior, self-picking, refusal of evaluation, and signs consistent with withdrawal, yet staff did not continue assessment or document the symptoms despite later discovery of fentanyl and methamphetamine in the resident’s possession.
A facility failed to transcribe and administer one resident’s ordered beta blocker and failed to hold another resident’s metoprolol when HR was below the ordered parameter. The DON and ADON said they were unaware of the missing order, and staff documented administration of the second resident’s medication despite low HR readings, with no documentation that the physician was notified.
A resident with a left hip surgical incision, anemia, diabetes, multiple myeloma, and anticoagulant use developed increased wound drainage and bleeding. Staff documented heavy sanguineous drainage and contacted the surgeon’s office, but communication broke down around the earlier office visit, the resident was not seen as planned, and there was no documented ongoing wound assessment for several days. The incision later dehisced with staples detached and bulging tissue, and the resident was then sent to the hospital.
Failure to Reorder Scheduled Alprazolam Led to Missed Doses and Withdrawal Symptoms: A resident with anxiety disorder, depression, and insomnia missed multiple scheduled doses of alprazolam after staff did not ensure the controlled medication was available for administration. The MAR showed repeated missed doses, and records noted the medication was out, on order, or unavailable, with no documentation that the physician or pharmacy was notified in time. The resident later reported withdrawal symptoms and a panic attack, and physician office staff observed the resident as red, sweating, shaking, tearful, and expressing hopelessness before the resident was sent to the hospital.
A resident with dementia, unsteadiness, repeated falls, and HTN had multiple falls with pain, confusion, and decreased mobility, but the chart did not show complete post-fall documentation, including ongoing neurochecks and 72-hour monitoring. Staff also did not include all assessment findings when reporting to the MD and did not transcribe ordered x-ray and blood test orders onto the POS.
A resident with cognitive impairment, bipolar disorder, and aggressive behaviors had a UA ordered to check for possible causes of the behavior changes, but the order was not entered into the chart timely and the urine sample was not obtained for eight days. Staff documented only one failed attempt because the resident was sleeping, with no other attempts or notifications to the FNP recorded. Interviews showed the nurse did not enter the order, did not document collection attempts, and did not notify the FNP when the specimen could not be obtained.
Delayed UTI Identification and Physician Notification Failure: A resident with autism, bipolar disorder, and severe ID had dysuria and cloudy urine, but the UA specimen was not collected and the physician was not notified when the resident continued to decline with dizziness, nausea, poor appetite, pallor, clammy skin, weight loss, and malaise. The resident was later sent to the ER and diagnosed with a UTI; ciprofloxacin was started without culture and sensitivity results, and the antibiotic was later changed after the culture showed it was not effective.
Skin assessments and wound care were not consistently documented or carried out as ordered for multiple residents. One resident had a sacral area that was documented as intact but was later observed with blood and an open area with slough; another had a right buttock pressure area with no treatment orders or progress notes; and a third had a left knee dressing with no timely wound orders in the record. Two other residents had physician-ordered wound treatments, but the TAR showed blank entries for multiple scheduled treatments.
The facility failed to thoroughly assess and monitor multiple residents after injuries from altercations and to follow wound treatment orders. One resident with right hand pain and swelling after being struck by another resident had an x-ray showing a fractured metacarpal that was not reviewed for several days, and physician orders for a hand splint and ice were not implemented or documented, despite ongoing pain and visible swelling. Another resident punched in the head/face had no documented neuro checks or focused monitoring after the incident, even though a skull x-ray was obtained and the physician expected neuro assessments. Two additional residents with hand and toe wounds had physician-ordered daily wound care documented as completed on the TAR, but observations and resident reports showed dressings were not changed as ordered, wounds were left with unchanged or no dressings, and the DON was not informed of at least one new wound, contrary to facility wound care and intensive monitoring policies.
A resident with cellulitis, gangrene, and a necrotic left great toe did not receive wound care fully consistent with the wound care FNP’s documented plan of care. The FNP repeatedly ordered daily cleansing with hypochlorous acid, Betadine application, and calcium alginate dressings cut to fit inside the wound, with changes daily and as needed. However, nursing staff entered physician orders that reduced treatment to every other day and omitted or altered the calcium alginate directions, and these discrepancies persisted over multiple weeks. Interviews with LPNs, an RN, the FNP, the physician, the DON, and the Administrator showed that all expected the electronic orders to match the FNP’s recommendations, but they were unaware that the entered orders did not reflect the specialist’s specified frequency and application method, resulting in a failure to provide care per standards of practice and the certified wound care plan.
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