Failure to Follow Physician Orders for BP Monitoring, PRN Midodrine, and Pro-Stat: The facility did not follow physician orders for three residents. One resident with HF and HTN had an order for BP checks supine and sitting every shift, but the eMAR had unclear rows and incomplete entries marked NA or single numbers. A second resident with ESRD and DM had a PRN midodrine order entered without BP parameters, even though staff noted the medication should have hold parameters. A third resident with pleural effusion, HF, chronic respiratory failure, ESRD on dialysis, severe cognitive impairment, and malnutrition had a Pro-Stat order that was not started for several days, resulting in missed doses with no documentation explaining the delay.
The facility failed to follow physician orders for behavior and side effect monitoring for several residents receiving psychoactive and other medications. eMAR entries used check marks, initials, 0, N/A, and other inconsistent codes instead of the required Y/N responses, behavior counts, intervention codes, and effectiveness documentation. Staff, including an LPN, RN/UM, DON, and LNHA, acknowledged that the orders were unclear or not followed, and one resident’s order required clarification because the documentation system did not match the written instructions.
A resident with a gastrostomy tube and dysphagia was care planned for EBP, but the EMR had no EBP order and staff initially observed no EBP signage or doorway identifier marking outside the room. The UM stated she was unaware of the policy for a resident care planned for EBP without an order, while the IP stated residents with gastrostomy tubes should be on EBP and that an order should be entered once care planned.
A resident with left arm and shoulder pain had a Lidoderm patch order that was not accurately tracked for application and removal, and an incomplete Voltaren gel order was not clarified for the application site. In a separate case, a cognitively intact resident with an unstageable pressure ulcer and nutritional risk did not receive the RD-recommended double protein portions, even though the recommendation had been emailed to the facility and the meal tray reflected only a single protein portion.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson’s disease, had a physician order in the EMR for a recheck test for Trichomonas. The EMR contained no documentation that the ordered lab test was completed and no lab results were available, and the DON confirmed that the test was not performed and no results were reported to the physician. This occurred despite facility policy requiring RNs/LPNs to carry out all physician orders and for incoming shifts and unit managers to check admission orders, resulting in noncompliance with professional standards of quality.
Failure to document and report repeated anticoagulant refusals. A resident with pelvic and other fractures was ordered Lovenox for DVT prevention, but the MAR showed multiple refusals over several months. The resident said they sometimes refused the injections because they questioned the need for them and disliked the abdominal injections. RN and MD interviews, along with record review, showed no documented progress note entries reflecting timely physician notification or resident education for the repeated refusals.
A resident with dementia, bipolar disorder, a history of falls, and severely impaired cognition had multiple documented falls, but the EMR showed no RN assessments for those events. The fall-risk care plan was initiated and managed by LPNs, was not updated to reflect the repeated falls, and the DON stated that LPN unit managers formulated the fall care plans and interventions.
Medication administration was documented before the meds were actually given for two residents during a med pass observation. An RN marked the eMAR as meds were prepared and checked them off as administered before entering the rooms, then gave the meds afterward. One resident had severe cognitive impairment with dementia and difficulty walking, and the other had moderate cognitive impairment with type 2 diabetes and GERD. The facility policy stated meds should be initialed on the MAR after each med is given and before moving to the next resident.
Missing physician order for hinged knee brace: A resident with a left tibia fracture was observed wearing a hinged brace on the left leg, and the resident described how the brace had been changed from a knee immobilizer to a hinged brace and later adjusted to allow bending. The LPN, LPN/UM, and RN/ADON reviewed the EMR with the surveyor and could not locate a PO for the brace. The chart included provider instructions for WBAT with the brace unlocked and only needed for walking, but no PO for the device placement or use.
Incomplete psychotropic medication monthly documentation was found for a resident with hydrocephalus, subarachnoid hemorrhage, coordination problems, dysphagia, and moderately impaired cognition. The PMMN entries did not match the psychiatric consult note or eMAR, listed incorrect target behaviors such as depressed mood and psychosis instead of restlessness, and omitted required episode counts and a psychiatry consult date. The DON stated nurses were responsible for the notes and that the documentation should match the reviewed month and the resident’s monitored behavior.
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