A resident with COPD on continuous O2, diabetes, heart failure, and multiple psychotropic and other meds had no documented administration of ordered medications or oxygen between late afternoon and late evening. The assigned RN assumed the resident was with a visitor, did not verify the resident’s location, did not administer 4 PM, 8 PM, or 9 PM meds, and did not notify the MD or RN supervisor of missed doses. For several hours, nursing and direct care staff were unaware of the resident’s whereabouts, and CNA safety checks and meal documentation stopped mid-afternoon. The resident was later found face down on the floor in the room, unresponsive, without O2 in place; CPR was initiated and EMS pronounced the resident deceased. Incident and nursing documentation did not reflect that the resident had been missing for hours, that medications and O2 were not provided, or that the resident was off oxygen when found, and leadership and the MD reported they were not informed of these facts at the time.
Surveyors found that wound care services did not meet professional standards when a wound nurse independently altered wound treatment orders for two residents with multiple pressure ulcers. For one resident with severe cognitive impairment and ventilator dependence, the nurse transcribed and implemented wound care at higher frequencies than ordered by the wound specialist, based on observed excessive drainage. For another resident with advanced neurologic impairment and facility-acquired pressure ulcers, the nurse documented and transcribed a change from Silvadene to Santyl ointment for a buttock ulcer that was not reflected in the wound specialist’s written order. The ADON reported limited recall of the nurse’s wound care competency and noted that nurses on the vent unit routinely provided more-than-daily dressing changes due to soiling, despite wound care being expected to follow specialist recommendations.
A resident with dementia, depression, and psychosis was re-admitted with an order for Clozapine 100 mg, 1.75 tablets at bedtime. The pharmacy notified the facility that the tablets could not be cut as ordered and requested a revised order using 100 mg and 25 mg tablets together, but staff did not obtain physician clarification at that time. An LPN continued to administer Clozapine over several days, including using 25 mg tablets intended for a different order without physician authorization, and the medication was not available at the scheduled administration time due to late pharmacy delivery. The original Clozapine order remained active until it was discontinued and rewritten days later, contrary to facility policy requiring prompt review and clarification of unclear or potentially inappropriate orders.
A resident with rectal CA, muscle wasting, and intellectual disability sustained an unwitnessed fall and was diagnosed in the ED with a left proximal humerus fracture requiring a sling, non‑weight‑bearing status, and specific orthopedic instructions. On return, facility staff did not complete a readmission assessment, did not notify a provider of the new fracture, and did not implement or obtain orders for the sling or related care. The care plan was revised only for general mobility issues and did not mention the fracture or sling, and direct care staff and therapy were unaware of the fracture despite observing bruising, pain, and limited ROM. Although the resident had a PRN acetaminophen order, documentation showed no administration for several days, including after the resident complained of pain, indicating that services were not provided in accordance with professional standards of quality.
The facility failed to follow physician orders and document care for multiple residents. One resident with heart failure and dementia had weekly weights ordered, but several ordered weights were either not obtained or not documented in the electronic record. Another resident with hypertension, dementia, and prior stroke had daily BP and heart rate ordered; however, on multiple days the BP and pulse were signed off as completed without numerical values documented, preventing verification that the vitals were actually taken. A third resident with CHF, COPD, and oxygen dependence was observed on continuous oxygen at a specified liter flow without any corresponding provider order in place at the time, despite staff acknowledging that oxygen is considered a medication and requires a medical order specifying flow rate.
A resident with CHF, HTN, and COPD had potassium chloride left on the bedside table instead of being directly observed as taken, while the MAR documented the medication as administered. The resident said staff brought the pills in the morning and they saved them for later, and staff interviews confirmed the medication was left in the room without an order for self-administration. The DON and RN manager stated meds were not to be left unattended and nurses were expected to stay until all meds were taken.
Failure to Follow Midodrine BP Parameters: A resident with hypotension and other diagnoses had a physician order for Midodrine with instructions to hold the medication if systolic BP was above 115 mmHg. Review of MARs showed the medication was given on multiple occasions even when systolic BP ranged from 120 to 142 mmHg. Interviews with the unit manager, RN, LPN, and DON confirmed staff had been reeducated on the protocol but continued to make the same medication administration errors.
A resident with moderately impaired cognition and a history of seizure disorder, hypothyroidism, and brain malignancy was discharged home after IV hydration orders were discontinued, but the IV access device was not removed and the discharge summary lacked instructions regarding IV access. Nursing notes indicated the resident was sent home with discharge medications, yet the facility’s discharge protocol requiring two-nurse verification of medications and removal of medical appliances was not followed, resulting in the resident being discharged with an IV access device still in place and a blister pack of medication that belonged to another resident.
A resident with anxiety, major depression, schizophrenia, anticoagulant therapy, tardive dyskinesia, and fibromyalgia did not receive all ordered bedtime medications when an LPN found that some medications were not in the med cart and did not use available pill packs in the med room. The LPN administered only narcotics and stock medications, failed to notify the nursing supervisor, pharmacy, or physician that medications were unavailable, and documented in the eMAR that all bedtime medications were given. There was no progress note indicating omitted doses or provider notification, and the resident later reported not receiving their medications and complained of worsened tardive dyskinesia symptoms, while the physician and nursing staff reported they had not been informed of the omissions.
A resident with heart failure, cardiovascular disease, and cognitive impairment had ongoing lower extremity edema documented, with nursing staff elevating the legs and obtaining a short course of Lasix when swelling increased. A Physician Assistant documented an order for compression therapy (intended as ace wraps) in a progress note, but at the time providers could not enter orders directly into the EMR and the PA did not communicate the order to nursing staff. The Unit Manager did not review the provider note, was unaware of the compression order, and reported that new orders were often not given to them directly. No compression order was entered into the EMR, no corresponding physician order or treatment entry was created, and no compression treatment was provided, despite expectations from the DON, Administrator, and RN Supervisor that Unit Managers or RN Supervisors promptly enter and implement new provider orders.
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