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.
A resident with PVD had a physician order to float heels in bed, but staff repeatedly observed both heels resting on the mattress and several nurse aides were unaware of the order. Another resident with dementia had no documented BM for several days, yet the bowel protocol was not started because he was not flagged on the BM report; he later developed vomiting, had imaging showing chronic constipation and a large stool burden, and required bowel medications and an enema after the delay.
Failure to Initiate Ordered Wound Care After Admission: A resident admitted after a left BKA did not receive ordered wound care to the new surgical site upon admission. The hospital discharge summary called for daily xeroform, gauze, ABD pad, Kerlix, and ace wrap, but the admission assessment and MAR/TAR showed no documented wound treatment until the Wound Nurse was alerted later and entered new orders. Interviews showed the RN, UM, and ADON did not identify or act on the surgical wound at admission, and the MD stated care should have started on admission per the discharge orders.
Failure to report and assess after a resident fall: A resident with severe dementia, weakness, and high fall risk was found on the floor by an RN and lifted back into bed without a mechanical lift. The RN did not document the fall or notify the oncoming nurse, MD, or RP, and an aide said the RN told her not to tell anyone. The next nurse later noted a red, swollen, warm LLE and contacted the NP for a venous doppler, but the resident’s condition worsened overnight with discoloration, a blue foot, and an obviously broken lower leg. The resident was sent to the ED, where x-rays showed acute displaced tibia and fibula fractures.
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