A resident with ESRD and an order for hemodialysis three times weekly missed dialysis treatments after becoming verbally combative and resistant to care. Staff notified the dialysis center and the resident representative, but the NP/MD was not notified that the behaviors were interfering with treatment, and the resident was not referred to contract psych services or grief counseling after his son’s death.
Failure to Care Plan Resident Behaviors and Psychosocial Needs: A resident with ESRD and intact cognition had repeated verbal outbursts, cursing, refusal of care and meds, and missed dialysis, yet the care plan did not address his behaviors or psychosocial needs. Staff, including an LPN, CNA, SSD, ADON, and DON, confirmed no specific interventions were in place despite awareness of the resident’s abusive language and impact on care.
Failure to Address Behavioral and Psychosocial Needs: A resident with ESRD and a traumatic amputation had verbal outbursts, cursing, and derogatory language toward staff, but was not referred for behavioral health or grief counseling after his son’s death. The resident missed dialysis treatments because of behavior and a funeral conflict, and the NP, SSD, and DON confirmed there was no notification to the provider or referral to in-facility psychiatric services despite available behavioral health support.
Missed Physician-Ordered Ice Therapy: A resident admitted after joint replacement surgery had a discharge order for ice to the operative area for post-op swelling and pain, but the order was not entered into the TAR, MAR, or physician orders. The resident’s advocate stated the ice was never provided, and the DON confirmed the order had been missed.
Incomplete Perineal Care After Incontinent Episode: A CNA provided incontinent care to a resident with feces in the brief but did not separate the labia while cleansing, and fecal material remained on the vaginal and anal areas after the brief was changed. The CNA later confirmed the resident was not fully cleaned, and the DON confirmed staff should have continued cleansing until no fecal material remained. The resident had vascular dementia, anxiety, dysphagia, a BIMS score of 6, and was dependent on staff for personal hygiene.
Failure to revise care plan after repeated falls: A resident with bilateral BKA and moderately impaired cognition had multiple falls after admission, including sliding off the bed during transfer and later being found on the floor beside the bed. Staff implemented fall interventions such as a floor mat, low bed position, and call light instructions, but the comprehensive person-centered care plan was not updated to reflect the resident’s change in condition or the individualized interventions.
The facility failed to follow comprehensive care plans for two residents. One resident required a total lift for transfers, but staff used a sit-to-stand lift instead, despite the resident’s severe cognitive impairment, dependence with transfers, and diagnoses including dementia and bone density disorders. Another resident had an order for EBP, but an LPN did not wear a gown during gastrostomy tube medication administration and had contact with the resident’s linens while providing care.
A resident with Alzheimer’s disease, dementia, severe cognitive impairment, and dependence for transfers was care planned for a total lift, but staff used a sit to stand lift instead. The CNA acknowledged not following the Kardex and care plan, another CNA assisted without checking the transfer instructions, and the NP, LPN, and DON confirmed the resident could not consistently follow commands and should not have been transferred with a sit to stand lift.
A resident admitted with an amputation and intact cognition had physician-ordered wound care for a right BKA site, including cleansing, Xeroform, ABD coverage, Kerlix wrapping, and scheduled dressing changes. Although the care plan addressed general wound monitoring, nutrition, rehab, pain, and psychosocial needs, it did not include the specific ordered wound treatment interventions. An LPN/MDS nurse and the DON both confirmed the wound care needs were not incorporated into the comprehensive care plan.
Failure to timely transcribe and document wound care orders: A resident admitted with a right BKA wound had hospital discharge instructions and physician-ordered wound care, but the orders were not entered into the EMR until days later and the wound treatments were not documented in the TAR or clinical record. An LPN said she provided the care but did not transcribe or document it, and the DON confirmed the admission process broke down when the paper orders were not entered by the RN who received them.
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