A resident with Barrett's Esophagus, DM2, and COPD did not receive a timely referral for routine endoscopy and colonoscopy as ordered by the prior NP. The resident said she assumed the appointment was being arranged, but the referral was not completed until much later, and the current NP, Scheduler, DON, and Administrator all described a breakdown in communication and order follow-through.
Failure to provide wound care for a resident with chronic venous insufficiency, varicose vein ulcers, and DM2 with neuropathy. A nurse documented open, blistered, weeping wounds on both lower legs but did not start treatment or notify the MD, PA, or oncoming staff. Another nurse later noted leg wounds with yellow craters and the resident said his legs were supposed to be covered but no one was doing the treatment. The resident was observed with large open, weeping wounds on both lower legs, and the MD and PA stated they had not been notified.
Failure to Communicate Pain Changes and Recognize Limited X-Ray Views: A resident with chronic pain, DVT, PAD, CAD, diabetes, dementia, and prior right leg surgery developed increased right leg/knee pain after a transfer incident that staff and family described differently, with inconsistent communication and documentation across shifts. The resident’s ordered imaging was incomplete because only one view was obtained for some studies, the radiologist recommended repeat standard views, and the provider was not told the exam was limited. The resident was later sent to the ED, where 3-view imaging identified a right femur fracture.
A resident with metastatic prostate cancer and severe cognitive impairment did not receive the oncologist-recommended 6-month follow-up, including PSA monitoring and reassessment. The facility scheduled oncology visits, but the appointments were missed and documentation was incomplete regarding cancellation, family notification, and transportation coordination. The RP denied cancelling the visit and stated the facility was expected to arrange transport and staff accompaniment when needed. The DON, UM, RN consultant, facility MD, and oncologist confirmed the follow-up did not occur and that the resident’s cancer status could not be reassessed.
Missed Pulmonology Follow-Up Appointment: A resident with acute respiratory failure with hypoxia and prior respiratory concerns missed a scheduled pulmonology follow-up because the facility did not ensure the appointment was communicated and transportation was arranged. The NP had ordered the consult, but the Medical Transporter was on leave, the Receptionist was unaware of the visit, and the outside wheelchair transport company did not provide transport, resulting in a no-show and later rescheduling.
Failure to Implement Ordered Bowel Regimen: A resident with dementia, CHF, and hospice care did not receive an ordered bowel regimen when hospice began, despite multiple days without a documented BM and standing orders for constipation management. Staff interviews showed bowel activity was expected to be tracked and escalated, but the hospice Senna Plus order was not started until after an ED visit revealed a large stool ball and fecal impaction on x-ray.
Failure to provide ordered wound care for a resident with a skin tear on the lower leg. The resident was cognitively intact and had a physician order for antiseptic cleansing, medi-honey, and a silicone bordered foam dressing with changes every 3 days and PRN, but the dressing remained unchanged for days and the resident reported staff had not changed it. Interviews showed the Wound Nurse was unaware of the wound, the ADON was unsure whether it had been communicated, and the nurse listed on the TAR denied completing the care.
Failure to Recheck Severe Hyperglycemia After Insulin Administration: A newly admitted resident with DM, a G-tube, and recent insulin changes had a FSBS of 509 after scheduled Humalog was given, but the nurse did not notify the provider or recheck the glucose. The resident had been NPO except for enteral feedings and was later found nonresponsive with fever, tachycardia, hypotension, and a hospital glucose over 1000, with DKA/HHS diagnosed.
Failure to Arrange Neurosurgery Follow-Up for Post-Op Staples: A resident admitted after a C4-T2 posterior fusion had a posterior neck incision with staples documented on admission, but the chart showed no neurosurgery follow-up appointment or staple-removal guidance from the hospital discharge paperwork. Facility notes repeatedly recorded the surgical wound, yet staff did not contact the neurosurgeon’s office for instructions. Interviews with the DON, Wound Care Nurse, Medical Director, and Neurosurgery office nurse confirmed that follow-up was expected and that staples are generally removed about 2 weeks post-op, but no facility call had been made until later.
Missed Physician-Ordered Daily Weights for Residents with CHF: The facility failed to obtain and document ordered daily weights for residents with CHF and other cardiac conditions. Records showed repeated gaps in MARs, weight sheets, and EMRs, and staff interviews confirmed that when no weight was documented, the weight often had not been done. The DON acknowledged missed weights had occurred, and the physician and NP stated daily weights were important for monitoring fluid status and CHF.
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