Failure to Obtain Ordered Urine Specimen for Suspected UTI: A resident with severe dementia, poor decision-making capacity, and frequent incontinence developed lethargy, increased confusion, urinary frequency, and strong urine odor. An NP ordered a UA with C&S to rule out UTI, but the order was not transcribed, no lab requisition was created, and no specimen was collected in the facility despite ongoing poor intake and family concern. The resident was later sent to the ED, where the urine sample was obtained by the hospital.
Medication administration records were incomplete for two residents. One resident with ESRD, DM, low BP, and hemodialysis had multiple scheduled meds and insulin doses not documented as given, with no nursing notes explaining the omissions. Another resident with DM, neuropathy, and heart disease had several scheduled meds and sliding-scale Novolog doses not properly documented, including missing unit amounts and blood sugar checks; staff also documented an insulin dose that did not match the order.
Failure to supervise and document monitoring accurately: A severely cognitively impaired resident with dementia, bipolar disorder, CHF, wandering behavior, and elopement risk exited the facility unsupervised and was not found. Video showed the resident leaving the grounds while the chart reflected LPN documentation of meds, VS, and monitoring later that morning, but the DON stated the LPN did not complete rounds and the overnight monitoring log showed the resident was not monitored. The exit door alarm also did not activate when the resident left.
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.
Failure to Address Repeated Refusals of Ordered Respiratory Medications: A resident with COPD, cerebral palsy, and severely impaired cognition repeatedly refused ordered inhaler and nebulizer treatments. The MAR showed numerous refusals of budesonide and ipratropium-albuterol, but there was no documented evidence that the MD was notified, that the consultant pharmacist identified the irregularities during monthly med reviews, or that the care plan addressed the refusals.
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 dysphagia, gastrostomy status, and severely impaired cognition did not receive the full ordered amount of enteral formula. The feeding was started on the evening shift, but by the next morning the resident was no longer connected to the pump and only 800 mL of the ordered 1200 mL had been delivered. An LPN documented that the full amount had been given without verifying completion, and the overnight LPN reported the pump alarmed repeatedly, the feed was paused and resumed several times, and it was stopped early to silence the alarm.
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.
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