Two residents did not receive ordered care as documented. One resident’s 9 AM meds, including BP, CHF, and asthma treatments, were omitted until mid-afternoon, and staff acknowledged the LPN did not give the meds on time or seek help. Another resident with urinary symptoms had a UA/C&S order that was not collected for several days, and there was no documented physician notification when staff could not obtain the specimen. The record showed the resident was incontinent and symptomatic, with delayed specimen collection and incomplete communication.
Delayed post-fall monitoring and imaging after unwitnessed fall. A resident with encephalopathy, AFib, CKD, and severe cognitive impairment fell from bed while receiving Eliquis and sustained a large skin tear to the right forearm. The incident report called for neuro checks and x-rays of the right shoulder and forearm, but there was no documented evidence that the one-hour neuro checks were ordered or completed in a timely manner, and no documented evidence that the imaging was completed before the resident was transferred to the ER.
A resident with dementia, impaired mobility, and muscle weakness had an unwitnessed fall that was not immediately reported by a CNA or assessed right away by a qualified staff member. The fall was later learned about when the resident told the spouse, and the resident had bruising to the left chest/abdomen area. The MD ordered a chest/rib x-ray to rule out fracture, but there was no documentation that the imaging was completed before the order was discontinued.
A resident with chronic anemia, AFib, and anxiety had a hematology consult ordered and repeated CBC/Mg labs entered, but the consult was not completed and the bloodwork was delayed for 14 days. Staff described breakdowns in the lab-order process between the NP, ward clerk, and phlebotomy, while the resident and family reported repeated concerns about fatigue, weakness, and the need for timely bloodwork. The resident later had critical Hgb values, was sent to the hospital for emergency transfusion, and the hospital documented acute on chronic anemia.
Medications were not available for a resident on admission, and ordered doses of Buprenorphine/Naloxone, pregabalin, clonazepam, valacyclovir, and topiramate were missed before pharmacy delivery. The MAR and nursing notes did not show documented administration, rationale, pharmacy contact, MD notification, monitoring, or alternate interventions while the meds were unavailable. The resident had Parkinson’s disease, herpes infection, major depressive disorder, bipolar disorder, opioid dependence, and intact cognition.
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with CAD, PVD, and COPD, who was cognitively intact, reported severe (10/10) pain and trouble breathing after family alerted staff that the resident felt very sick. An RN documented stable VS and no acute distress, and later an NP was contacted and adjusted pain medications. That evening, nursing notes described a significant two-day decline with minimal intake, continuous sleeping, and persistent 10/10 foot pain despite the new regimen, but there was no documented provider notification of this ongoing uncontrolled pain and change in condition. By early the next morning, the resident was very lethargic, non-responsive, hypotensive, and was then sent to the ER, where they were diagnosed with toxic metabolic encephalopathy likely due to severe sepsis from gram-negative pneumonia. The NP stated nurses were expected to call back with reassessment if pain remained uncontrolled, the DON was unaware of the change in condition, and an RN acknowledged documentation should have been better, demonstrating a failure to follow change-of-condition and quality-of-care policies.
A resident with acute UTI, Parkinson's disease, and Lewy body dementia had a care plan requiring antibiotics and a physician order for Amoxicillin 500 mg every eight hours for six days, but three of the 18 ordered doses were not administered. The MAR for the month showed omissions for specific scheduled doses with no corresponding documentation, and nurse's notes contained no explanation for the missed doses. In interviews, an LPN unit manager confirmed that lack of MAR documentation meant the medication was not given and acknowledged the omissions were preventable, while the DON stated the expectation that there be no omissions and that any non-administered medication be documented with a reason.
A resident with CHF had ordered daily weights missed on multiple days, including instances where weight gains exceeded ordered parameters without provider notification. Another resident with dementia had a left elbow bruise that was not identified or documented during the weekly skin inspection. A cognitively intact resident had Tylenol left at bedside for self-administration without an active MD order authorizing it, despite staff confirming that such an order was required.
A resident with recent critical illness, respiratory needs, a modified diet, and abdominal wound/drain care was admitted without a timely RN admission assessment, and ordered treatments, monitoring, and labs were not documented as completed. The chart also lacked evidence of BiPAP orders, wound/drain assessments, or incentive spirometry. When the resident left AMA, there was no documentation of who they left with, whether education was provided, or whether a medical provider was notified.
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