Two residents did not receive timely follow-through on ordered lab testing. One resident with sepsis risk factors had CMP, CBC, CRP, HgbA1c, and ESR orders, but specimens were not collected until 3 days later; the resident was later found unresponsive, CPR was started, EMS was called, and the resident was pronounced deceased. Another resident with acute kidney failure, CKD, acute respiratory failure with hypoxia, COPD, DM2, HTN, A-fib, PVD, and an unstageable pressure ulcer had ordered potassium, magnesium, CBC, CMP, and CRP testing, and was later transferred to the hospital for edema, AMS, and hypotension. Staff interviews showed they were not aware of the pending labs or monitoring needs, and the MD stated suspected sepsis labs should be obtained the same day or by the following morning.
Failure to notify the provider when ordered insulin was not administered: A resident with DM had orders for Novolin 70/30 and NovoLog sliding scale insulin, but the MAR showed multiple instances of partial doses, held doses, and a refusal of insulin. Staff documented several blood glucose readings with no insulin given, and the NP stated nursing staff should contact the provider when a resident requests a partial dose or refuses insulin and should administer sliding scale insulin as ordered.
IV Antibiotic Not Administered as Ordered: A resident admitted with sepsis and endocarditis had an order for IV Ampicillin q4h, but the IV tubing remained clamped and the dose was given 2 hours and 30 minutes late. RN, the UM, and the DON all confirmed the resident did not receive the IV antibiotic as ordered because the clamp was not opened.
A resident with hypertensive heart disease with heart failure had an order for diltiazem 120 mg daily, to be held if SBP was below 110, DBP below 60, or HR below 60. Staff administered the medication even though the resident's BP was 127/50 and HR was 52. The DON stated staff did not follow the physician's order and that the medication should not have been given outside the ordered parameters.
A resident with a cough and phlegm reported that the facility MD said cough syrup would be prescribed, but he had not received it. The provider note documented Robitussin cough syrup, yet the MAR/orders did not include the medication. An RN stated the ADON accompanies the MD during resident visits and enters new orders, and confirmed the resident had no cough syrup order.
Failure to Monitor Ordered Weights: Two residents at risk for malnutrition had physician-ordered weekly weights for four weeks and then monthly weights, but staff documented only two weights for each resident and did not complete the ordered weekly monitoring. The DON confirmed the weights were not performed as ordered.
A resident with a history of cerebral infarction, dementia, and glaucoma did not receive ordered Dorzolamide HCI-Timolol Maleate eye drops after an LPN accidentally discontinued the medication in the system without a physician’s order. The MAR showed the drops were not administered because no active order was available, and nursing documentation later confirmed the facility had discontinued the eye drops without provider authorization. In interviews, the administrator and DON acknowledged that the medication had been stopped in error and that there was no physician order to discontinue it.
A resident with ESRD had physician orders and the care plan listing dialysis for Monday, Wednesday, and Friday at 6:00 am, but the resident stated dialysis was actually occurring on Tuesday, Thursday, and Saturday at 11:45 am. The DON confirmed the dialysis schedule had changed and that the orders and care plan should have been updated to match the new schedule.
Surveyors found that two residents were receiving clinical interventions without required physician orders. One resident with serious neurological diagnoses was observed using O2 via nasal cannula with an O2 concentrator in the room, but record review showed no corresponding physician order, despite facility policy requiring an order specifying flow rate, method, usage, and indication. Another resident was observed with a Foley catheter collection bag hanging from the bed, yet no physician order for the catheter was present in the record, contrary to the facility’s catheter policy requiring medical necessity and valid justification. An LPN, the ADON, and the DON all confirmed the absence of appropriate orders for these treatments.
Two residents experienced deficiencies in care when staff did not follow physician orders for oxygen therapy and STAT diagnostics. One resident with COPD and acute respiratory failure had orders for continuous O2 at 5.5 LPM via nasal cannula, yet was repeatedly observed with the portable O2 device turned off or set below the ordered flow, without a nasal cannula attached, and with an empty portable tank, resulting in low O2 saturations on room air. Staff acknowledged the resident required assistance with O2 therapy, and a CNA reported removing the nasal cannula and not replacing it. Another resident recovering from a right femur fracture developed severe left knee pain with swelling and decreased range of motion; an after-hours provider ordered STAT CBC, CMP, CRP, and a STAT left knee X-ray, but these were not completed because the orders were not documented correctly, causing a delay. The DON confirmed that O2 was not provided as ordered and that STAT labs and imaging were not obtained immediately due to documentation errors.
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