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.
A resident with a recent below-knee amputation and ongoing orthopedic wound care missed a scheduled ortho follow-up because the facility’s transportation plan was inaccurate. The appt calendar showed family transport, but the resident said family was unavailable and staff had not confirmed the plan; the RN and Transportation CNA described a breakdown in communication about who would provide transport.
A resident with CVA-related weakness and contractures was observed without ordered splints in place, even though the MAR had been signed as if they were applied; the RN confirmed the splints were not on the resident and had been charted before application. Another resident with bilateral leg pain, onychomycosis, and skin dryness had antifungal ointment documented as administered on the TAR even though the medication was not in the cart and was not applied, and the DON confirmed it should not have been charted as given.
A resident with plagiocephaly and other complex diagnoses was observed wearing a cranial helmet, but the physician order for 23-hour wear with a daily one-hour removal and cleaning was not properly carried out or documented. The e-MAR remained blank, daily nursing assessments did not show the required removal and cleaning tasks, and the DON confirmed nursing was responsible for following the order while the POC record only reflected helmet cleaning.
A resident with a left patella fracture, metabolic encephalopathy, depression, and mood disorder had a knee brace from PT that was applied by restorative nursing, but the chart lacked a physician order, RNA notes, and a care plan for the brace. Staff reported the resident often refused the brace because of pain and wanted it removed, and the MDS/medical records staff confirmed the missing documentation.
A resident with dementia and other diagnoses had a physician order for 1:1 meal assistance with aspiration precautions, but staff did not consistently provide or document the ordered feeding support. The resident was observed with meal trays left at the bedside, stated no one helped with feeding, and staff gave conflicting descriptions of the resident’s level of assistance, with the RN confirming the order was not followed.
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