Failure to administer ordered IV fluids: A resident with AKI, CKD, and acute respiratory failure had an order for LR 250 mL IV PRN with reassessment after each bolus, but the TAR showed no LR bolus was given as ordered. The resident was later transferred to the ER for edema, AMS, and hypotension, and the NP stated the LR was intended to be given one bolus at a time with reassessment, not as three consecutive boluses.
A resident with a history of falls, osteoporosis, and difficulty walking sustained an unwitnessed shower fall and later reported shoulder pain. An x-ray showed a left humerus fracture, and the provider ordered a sling, non-weight bearing status, and an orthopedic referral, but the facility had no documentation that the referral was scheduled or completed. The resident said she had not seen an orthopedic specialist and wanted to discuss whether surgery was an option, while MR stated nursing never forwarded the referral for scheduling.
Failure to Supervise Nursing Student During Meal Delivery: A nursing student delivered a breakfast tray to a resident with an active NPO order after being directed by a CNA, without verifying the resident’s identity or diet order. The resident, who had dysphagia, PEG dependence, aspiration pneumonia, and acute respiratory failure with hypoxia, consumed part of the meal before staff removed the tray. The resident later developed chest congestion, low O2 saturation, worsening lung sounds, and was transferred to the ER with findings concerning for aspiration or multifocal pneumonia.
A resident with DM2 and diabetic neuropathy did not receive ordered sliding-scale insulin after returning from the hospital, despite a history of insulin use and hospital administration of insulin lispro. The MAR showed numerous elevated blood glucose readings, including readings over 300 and over 400, with no sliding-scale insulin given during the reviewed period. The DON stated the floor nurse should obtain and clarify discharge orders, and the MD stated the resident fell through the cracks on readmission.
A resident with pneumonia did not receive all ordered doses of amoxicillin-clavulanate. Staff documented missed doses on two days, with one note stating the resident was not in the facility, but the record did not show provider notification or an order to extend the antibiotic so the resident received the full course. Nursing staff and the DON/RNC confirmed the missed doses and stated the medication should have been given after the resident returned from dialysis.
A resident with a recent hospital stay for severe AKI and dialysis had visible bilateral leg swelling that was observed by surveyors, while the resident said he did not know what staff were doing for the edema. Nursing notes did not document assessments for several days, an LPN was unaware of the edema until interviewed, and the provider later documented 3+ pitting edema in both legs and ordered furosemide.
A resident with COPD, acute respiratory failure, pulmonary fibrosis, and recent hospitalization for UTI and sepsis returned from the hospital on palliative care with an order for continuous O2 at 2 L/min via nasal cannula. After arrival, staff removed the ambulance’s portable O2 and attempted to use the facility’s O2 concentrators, which were ineffective, while the resident was restless and grabbing at the air. The resident’s daughter reported a period without O2 while staff tried different concentrators and searched for equipment, estimating about 15 minutes before a portable O2 tank was brought back, at which point the NP pronounced the resident deceased. The DON later questioned why a portable O2 tank had not been used when the concentrators failed, and the NP stated the concentrator in use at the time of her assessment was not working properly.
Failure to monitor a resident's edema. A resident with DM2, anticoagulant use, and edema had a nursing summary note recommending monitoring for increased edema and physician notification if present. He was observed with visible redness and swelling in both lower legs and reported daily swelling while taking a diuretic, yet the physician order for furosemide had no edema monitoring in place. The DON confirmed the resident had edema and that monitoring was not provided.
A resident receiving hospice care had pneumonia, fever, and hip pain, but hospice and facility staff did not coordinate care as expected and hospice visit notes and orders were missing from the chart. The resident’s record showed mismatched facility orders for doxycycline, prednisone, and acetaminophen, while staff gave conflicting accounts about a delivered pain medication and whether a valid order existed. The DON, RN, and MRC confirmed hospice documentation was not in the medical record.
A resident with osteomyelitis and cellulitis of the lower limb did not receive a newly prescribed doxycycline antibiotic after a podiatry visit, despite facility staff being aware of the order and the need for treatment. The prescription was sent to an outside pharmacy but was never ordered by the facility, and the medication was not administered during the days following the prescription. The resident reported ongoing swelling, pus pockets, and severe pain and stated that staff were informed of the need for the antibiotic. The discharge medication list did not include doxycycline, and the resident was discharged without documented access to the prescribed antibiotic, as later confirmed by the DON.
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