A resident with hemiplegia, DM2, and convulsions was admitted with an order for IV Vancomycin for infection, but the medication was not properly reconciled at admission and was not given when ordered. The admitting LPN expected the next shift to complete reconciliation, the order was not entered into the computer, the pharmacy delivery was delayed, and the first documented dose was not administered until the following day.
A resident receiving IV vancomycin and ertapenem for a sacral pressure ulcer with cellulitis was discharged with a midline catheter in place even though there was no PO to keep it in place or remove it. The LPN who completed the discharge said she did not perform a head-to-toe assessment and did not know the resident had the midline. Staff later went to the resident’s home to remove the catheter, and the DON, UM, NS, and physician all stated the resident should not have been discharged with IV access without a PO.
A resident with significant mobility limitations fell and reported pain, but only an LPN assessed the resident; there was no RN assessment or documented ROM comparison, and the resident was later found to have an acute right hip fracture. Another resident with sepsis-related diagnoses had a sudden decline with shaking, altered responsiveness, and abnormal vital signs, but the LPN delayed escalation and recheck of vitals before calling 911, and the resident was later admitted to the hospital for sepsis.
A facility failed to provide care in accordance with professional standards when two residents were observed double diapered, with the inner brief wet and the outer brief dry. A CNA admitted to the practice and said it was done because of short staffing, while the CNA, LPN, ADON, and DON all stated that residents should not be double diapered because it can cause skin breakdown and is not appropriate care. The residents had incontinence-related care needs, and one had documented risk factors for skin impairment.
A facility failed to complete a timely initial nursing assessment for a newly admitted resident, failed to document administration of a physician-ordered PRN Lomotil, and failed to consistently document and coordinate hospice services in the resident’s record. Surveyors found no baseline nursing notes for the first days after admission, no MAR signature or explanation for the omitted med, and gaps in weekly hospice documentation for a resident with severe cognitive impairment and multiple chronic conditions.
A resident with influenza, dysphagia, seizures, heart disease, and dementia had refused meds and meals and later developed abnormal vital signs, including low BP, low temperature, lethargy, and low SpO2. The nurse informed the supervisor and monitored the resident, but there was no evidence the physician was notified of the abnormal findings before the resident was transferred to the hospital with respiratory distress.
A resident with pressure injuries had duplicate wound treatment orders for the same site, and an RN documented a wound treatment as completed in the eTAR before actually performing it. Another resident with DM had no care plan focuses or interventions for diabetes, and although a BG of 473 was treated with Humalog per sliding scale, there was no documentation that the physician or NP was notified as ordered.
A resident with multiple comorbidities, including recent pneumonia, thrombocytopenia risk, and renal issues, had weekly CBC/BMP labs ordered. One set of labs showed a critically low platelet count and significantly worsened renal function. The overnight LPN received the critical values and sent a text to the physician instead of establishing direct voice contact, then later texted about another resident. The physician only saw and responded to the second text and stated he never saw the message about the critical platelet count. No direct call was made, no new orders were obtained, and the critical results were not effectively communicated for approximately three days. The issue came to light when the resident’s representative questioned the labs during a care plan meeting, prompting a unit manager to call the physician, who then reviewed the results and ordered transfer to the ER. Interviews and policy review showed that facility expectations and protocols required emergent, direct phone communication and escalation for critical labs, which did not occur in this case, resulting in delayed care and treatment.
A resident with severe cognitive impairment had a newly identified skin tear on the upper arm that was dressed without an individual physician order, and the wound order was entered for the wrong body location. In a separate issue, another resident’s milk allergy and multiple hospital-documented allergies were not transcribed into the admission record, allergy roster, care plan, or meal selection sheets, despite the resident later confirming the milk allergy to the RD.
A resident receiving hospice care had hospice recommendations for morphine for pain/dyspnea and lorazepam for muscle spasms, but the chart showed only one morphine order and no lorazepam order, with no PN documenting physician disagreement. Another resident with ESRD and diabetes had fluid restriction and hypoglycemia orders that were not followed as written: the chart lacked required documentation of fluid amounts, MD notification for low BS, administration/sign-off of PRN hypoglycemia treatments, and documentation that BS checks and change-in-condition notifications were completed.
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