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.
A resident with depression, chronic pain, and multiple psychotropic and pain medications called a suicide hotline, reported feeling isolated, and disclosed hoarding acetaminophen with intent for self-harm. The ADON documented the hotline contact and a behavior monitoring order was entered to track episodes of sadness, suicidal thoughts, suicidal tendencies, and agitation, with findings to be documented and the provider notified. Despite this order and a facility policy requiring mood and behavior monitoring and documentation after suicide threats, the administrator later acknowledged that no behavior monitoring documentation could be found. That same evening, after a second hotline call and an assessment by an LPN, the resident’s roommate reported the resident was shaking a pill bottle and threatening to take all the pills; the LPN then found an empty pill bottle and the resident was sent to the ER. Interviews with staff and family confirmed that medication remained at the bedside and that staff believed the issue was resolved, but there was no documented ongoing behavior monitoring as ordered.
A resident with type 2 DM and an FSBS of 64 had existing physician orders for Glucagon, oral carbohydrates, and physician notification for blood sugars below 71, but nursing staff did not administer the ordered Glucagon or notify the physician and instead gave 40 units of long-acting insulin. The facility’s policy required following physician orders based on FSBS results, and the medical director later stated they would not expect long-acting insulin to be given in this situation. The next morning the resident was found unresponsive, EMS documented an FSBS of 41, and the resident was sent to the hospital, leading surveyors to cite a deficiency for failure to assess, monitor, and intervene for hypoglycemia.
A dependent resident with moderately impaired cognition and chronic pain returned from the ER and was assisted to bed by a CNA and an LPN, who moved the resident up in bed by having the CNA reach across and pull the draw sheet from both sides while the LPN lifted under the knees, rather than positioning one staff member on each side of the bed and using the draw sheet correctly. The resident reported calling out that their arm hurt during the maneuver, but the staff continued the movement, and the resident was later observed with a bandage and dark purple bruising on the forearm. Other CNAs, an LPN, and a restorative aide described the correct repositioning method and indicated that a pain complaint should trigger assessment and appropriate response.
A resident with severe cognitive impairment, septicemia, renal failure, and IV access had a physician order for weekly IV midline dressing changes on day shift, or sooner if the dressing became compromised. Review of the MAR showed a scheduled dressing change was missed without a documented reason, and a family grievance later reported the IV dressing had not been changed since admission and was dated nearly two weeks earlier. Nursing staff told the family the dressing change was missed because the resident was at dialysis when it was scheduled, and documentation and interviews with the DON and regional nurse consultant confirmed there was no record of the ordered IV dressing change being completed as required.
A resident who was cognitively intact but required substantial/maximal assistance and two-person help for toileting and transfers sustained two separate left arm fractures when staff did not follow the care plan or facility transfer policy. On one occasion, a CMA used a one-person transfer to the bathroom despite the resident stating they needed two-person assistance, and the resident fell and fractured the left arm. On another occasion, two CNAs transferred the resident to a shower chair by lifting under the arms instead of using a gait belt or approved technique, and a pop was heard in the resident’s shoulder, followed by confirmation of a left humerus fracture. The DON later stated staff were to use gait belts and not lift residents under their arms.
Failure to obtain ordered daily weights for a resident with stage 3 CKD who was receiving dialysis and had fluid restrictions. The physician ordered daily weights and PCP notification for a weight gain over 3 lbs in 24 hours, but the record showed multiple missed weights. The ADON confirmed the resident had not been weighed per the MD order, and the administrator stated the expected weighing window was between 5:00 a.m. and midnight.
A resident with significant neurologic and bladder-related diagnoses had an open area and scabbed areas on the buttocks, but weekly skin assessments were not completed after the last documented assessment. In a separate case, an LPN did not follow the updated wound treatment orders for another resident’s ankle/lower leg wound, and the resident’s chart was not updated when the wound care provider changed the treatment plan.
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