Wound care was documented as completed for a resident with a right heel wound, but the dressing was not in place and the care had not actually been performed. The resident had an open wound with bleeding from the heel, and the floor LPN and Wound Care LPN each indicated the other was responsible for the treatment, while the DON stated the treatment should not have been charted complete unless it was done.
A resident with type one DM was admitted after a toe amputation, but the facility did not obtain a baseline BG, did not clarify hospital discharge notes about SSI and splitting long-acting insulin with the attending physician, and did not secure clear BG monitoring orders. When the resident later had a change in condition with abnormal VS and AMS, no BG was obtained before EMS transfer. The resident was hospitalized with severe hyperglycemia and DKA, and the facility confirmed it had no diabetes management protocol.
A resident with a GI infection had a lab result showing C. diff was negative but Entamoeba histolytica was positive, yet the record lacked documentation that the established GI specialist was notified and the care plan did not include the parasite infection. Another resident reported constipation, nausea, and abdominal and rectal pain, with the bowel record showing multiple days without a BM; although PRN Fleet enema and Milk of Magnesia were ordered, no administrations or other constipation interventions were documented.
A resident with dementia, COPD, and rhabdomyolysis had an order for SCDs to both lower extremities while in bed, but staff documented the treatment as provided even when the SCD machine was not turned on and later found stored in a bedside chair. Another resident with hyponatremia and AKI had a 1,000 mL fluid restriction, yet a water pitcher and cup were left in the room and the resident was served fluids that exceeded the dietary restriction noted on the tray ticket.
Feeding a Sleeping Resident: A CNA fed a resident while the resident was asleep and lying flat in bed, with food falling from the resident’s mouth onto the face and clothing. The resident had dementia, insomnia, and anxiety, and staff stated the resident had been sleeping through the day and night for about two weeks. The CNO confirmed residents should be awake and positioned upright when assisted with eating, and the care plan indicated the resident could eat independently with supervision and tray set-up/clean-up assistance.
A resident with multiple medical conditions, including encephalopathy and anemia, had a physician order for Megestrol Suspension as an appetite stimulant to be given twice daily within specific time windows. During a morning med pass, an RN administered several medications but omitted the ordered Megestrol, later confirming it remained in the med cart and that the order had not been followed, despite facility policy requiring adherence to physician orders. In a separate case, a newly admitted resident with encephalopathy, multiple sclerosis, epilepsy, and dementia had hospital discharge instructions for a Neurology follow-up within one to two weeks, but the facility did not arrange this appointment, even though the admissions process requires reviewing discharge summaries and setting up needed follow-up care.
Delayed Administration of Ordered Antibiotic: A resident with DM2, PVD, lower-extremity arterial thrombosis, and a surgical wound infection had an order for Bactrim DS BID at 0800 and 2000. The MAR lacked documentation that the 0800 dose was given on time, and an LPN stated the dose was administered later because time had gotten away from her; the DON confirmed the medication should have been given at 0800.
Failure to document and carry out CHF-related orders occurred for a resident with CHF, NSTEMI, pleural effusions, AFib, and CKD. The resident had no HF care plan or documented HF goals, a 1500 mL fluid restriction was not clearly tracked, a six-pound weight gain was not reported to the provider, and intake/output was not documented. IV fluids were ordered for dehydration, but there was no documentation that they were given or why they were not started, and a chest pain episode with lethargy and SOB was not documented in the EMR.
A resident with a G-tube and functional quadriplegia had repeated tube dislodgements that led to hospital transfers, and the physician order for tube care did not include instructions to prevent displacement; on observation, no abdominal binder was in place. Another resident with lymphedema and chronic venous stasis ulcers was observed wearing compression devices with severe leg pain, but the record lacked a physician order and wearing schedule for the compression device, and staff and the DON confirmed the management orders were not in place.
A resident with dementia, Alzheimer's disease, and CKD had conflicting code status documentation: a physician order listed DNR while the POLST listed Full Code and noted the resident lacked decisional capacity. The UM confirmed the mismatch and could not determine the correct code status, while the SSD found no documented family discussion about code status since admission and the DON stated the physician order should correspond with the POLST.
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