Medication Error and Failure to Follow Physician Orders: A resident with MS had an order for oxycodone-acetaminophen PRN for pain, but staff gave the wrong medication instead of the ordered dose. The CMA notified the nurse, and the error was documented; the resident was alert and oriented with no signs or symptoms of distress, and the physician, DON, Administrator, and family were notified.
Failure to assess and provide care for a resident with edema. A resident with severe cognitive impairment was observed with swollen feet, and the record lacked a completed baseline care plan and a complete admission assessment. Nursing documentation later noted edema in the extremities and feet, while staff interviews showed the CNA had noticed purple feet without checking them and the RN had not assessed the pedal areas. The DON stated staff should have been checking for edema every shift and documenting findings.
Failure to Follow Physician Orders for Labs, Dressing Care, and Ice Packs: A resident admitted after joint replacement surgery reported that staff did not complete ordered admission labs, surgical dressing changes, or ice pack applications. The record contained orders for CBC, CMP, prealbumin, incision cleansing and dressing changes, and ice packs for pain, but there was no documented evidence these treatments were carried out. The DON confirmed the lack of documentation, and the Administrator stated staff were expected to follow provider orders or notify the provider if unable to do so.
A resident with essential hypertension had an order to notify the physician if SBP was above 160 mm/Hg, but multiple elevated BP readings were not reported or documented. Staff interviews showed CMAs collected vitals, nurses were expected to notify the physician through an encrypted messaging system, and the Medical Director found no indication he had been informed of the abnormal readings.
A resident with acute kidney failure and CHF had a physician order to document fluid intake three times daily, but the ADL administration history showed repeated missed documentation of fluids consumed with meals over an extended period. During interview, the DON stated the 1400 mL fluid restriction was not documented appropriately and that the order would be added for nurses to complete.
Failure to follow wound vac orders for a resident with an abdominal surgical wound and multiple diagnoses, including DM2 and a skin infection. The wound vac was observed turned off and the dressing was not dated, while an LPN stated it had been off since the start of the shift and did not know how long it had been off. The physician order required removal of the vac dressing and alternate wound care if the device was off for more than two hours, and the DON stated the LPN did not follow the order.
Failure to Monitor and Respond to Resident Decline: A resident with stroke, CHF, hemiplegia, DM2, and severe cognitive impairment showed poor intake and abnormal behavior earlier in the day, but staff did not promptly document, assess, or escalate the change in condition. By evening, the resident was lethargic, unresponsive, and sent to the ER with abnormal VS and elevated blood sugar; the EMT reported the resident was alone in the room and had likely been unresponsive for hours.
A resident with recent abdominal aortic aneurysm repair and a history of circulatory surgery was on multiple anticoagulant and antiplatelet agents (Eliquis, aspirin, Plavix) and had care plans directing staff to monitor for and report abnormal labs and signs of bleeding, including black or bloody stools. A critical hemoglobin of 6.3 g/dL was reported by the lab, which documented unsuccessful attempts to reach nursing staff; the result was later signed by facility staff, but the DON confirmed the physician was never notified and no intervention was documented. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding with screaming, shortness of breath, and anxiety while on the toilet; an ACMA notified an LPN, who did not promptly assess the resident and instead instructed continued monitoring and attempts to convince the resident to go to the hospital. Nursing notes and EMS documentation showed a significant hemorrhagic event with extensive blood in the room and on the resident, yet there was no evidence of ongoing assessment, monitoring, or timely physician notification for the change in condition or the critical lab, leading surveyors to cite a deficiency under F684 for failure to provide appropriate treatment and care according to orders and the resident’s condition.
A resident with DM2, acute kidney injury, and a recent history of hypoglycemia-related hospitalizations was admitted without care plan interventions for diabetes or kidney injury and without parameters for PRN Glutose or glucagon. Over several days, no finger stick blood sugars were documented despite ongoing use of Metformin and glimepiride. The resident developed critically abnormal VS, including hypotension, hypoxia, bradycardia, and unresponsiveness, with documentation gaps showing no or unclear provider notification and no recorded interventions for some abnormal readings. Staff later reported they believed they had notified the NP about low VS, but could not find documentation, and the NP stated they had not been notified of these changes and had expected routine blood glucose monitoring. The resident was ultimately found unresponsive with severe hypoglycemia and was transferred to the ED in critical condition, and the situation was cited as an IJ for failure to monitor and intervene for hypoglycemia and acute changes in condition.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
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