Failure to Document and Implement Verbal Nystatin Order: A resident with encephalopathy, cachexia, and severely impaired cognition had a fungal rash to the sacrum and anus, and an NP gave a verbal order for Nystatin cream and a wound consult. The order was not transcribed to the MAR/TAR, the Order Summary did not show it, and there was no nursing documentation of the NP evaluation or implementation of the verbal order.
A resident with metabolic encephalopathy, pneumonitis, and CKD had an acute decline with respiratory distress, low BP, and worsening oxygenation. The MD ordered hospital transfer, but an RN called a transport company instead of 911, and the resident remained in the facility for hours while condition worsened. The resident was later sent to the hospital and admitted to the ICU with septic shock; the DON, previous DON, unit manager, LPN, and MD all confirmed 911 should have been called.
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.
Missed Documentation of Ordered Wound Treatments: A resident with a stage 4 sacral PU, an unstageable PU, DM2, and significant cognitive and mobility impairments had physician-ordered Dakins and Santyl wound care documented with multiple blank TAR entries on day and evening shifts. The RN/UM and DON stated blank TAR boxes meant the nurse did not sign that the treatment was completed, and there was no way to verify completion unless the TAR was marked completed.
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 severe cognitive impairment and a recent fall had video monitoring in place, but the room lacked required signage and the record did not contain written consent from the RR, despite staff stating verbal consent had been obtained. In a separate case, a hospice resident with dementia and repeated medication refusals had hospice recommendations to discontinue several meds and supplements, but the physician documentation only clearly addressed Eliquis and the remaining recommendations were not clarified in the record until after surveyor inquiry.
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.
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