A resident with Parkinson's disease, cognitive communication deficit, and dementia had a scheduled Sinemet order with specific administration times, but the MAR showed the times were changed by the DNS to simplify the CMA workflow without a documented provider order or resident discussion. Staff later stated a physician order was required for the change, and the resident's family was upset with the altered med times.
The facility failed to timely implement physician orders for two residents. One resident with urinary symptoms and a UTI had delayed antibiotic treatment because culture and sensitivity results were sent to the wrong location and were not available in the EHR. Another resident with osteomyelitis, DM, and pressure injuries had a doxycycline order started 6 days late because the faxed order was received through a limited-access fax number.
A resident with heart failure, renal dialysis dependence, and moderate cognitive impairment had a physician order to call the covering provider for HR above 100 bpm or below 55 bpm. The resident’s HR was documented below range on two occasions, but the record showed no provider notification, and staff interviews confirmed the abnormal readings were expected to be communicated, rechecked, and documented by the nurse.
A resident with hypothyroidism did not receive ordered levothyroxine once daily for several consecutive days, and there was no documentation in the clinical record explaining the missed doses. The DNS acknowledged the missed medication administration.
The facility failed to carry out ordered bowel care for two residents. One resident with chronic pain and heart failure went 5 days without a BM, with only docusate given and no other ordered bowel meds attempted. Another resident with kidney failure had two prolonged constipation episodes, including 11 days and 7 days without a BM; PRN laxatives and suppositories were given late or not at all, and staff acknowledged the resident was often on alert for not having a BM.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
A resident with CVA, hemiplegia/hemiparesis, and moderate cognitive impairment had an unwitnessed fall, but staff did not complete a full-body skin assessment after the event. An LPN said clothing was not removed to check for injuries, an RN later said a skin check missed leg injuries, and a unit manager said she expected full-body skin assessments after falls. Healing abrasions were later found on both knees, and the resident said the injuries happened when he/she fell out of the wheelchair.
Failure to Administer PRN Insulin per Order: A resident with DM had physician orders for PRN Insulin Lispro when CBG was greater than 400, but the DAR showed multiple elevated CBG readings without the PRN insulin being given. The record also lacked documentation that the CBG was rechecked after the high readings, and an RN verified there was no documentation of rechecks or PRN insulin administration.
A resident with ESRD, conjunctivitis, and a perforated corneal ulcer did not receive ordered erythromycin ophthalmic ointment on multiple occasions. The MAR showed missed doses when the resident was at dialysis or absent from the home, and there was no documented evidence that the provider was notified. Staff interviews showed the CMAs documented the resident as out of the facility but did not communicate the missed eye medication to nursing staff.
Failure to clarify and follow a resident’s daily weight order occurred for a resident with HF, AFib, and COPD. The TAR showed ordered daily weights, but weights were missing on multiple days while the resident had repeated weight gains, including a 10-lb increase over several days. Chart notes referenced weight warnings and monitoring, but staff reported there were no documented parameters for reporting weight changes and the DNP was not notified when the resident’s weights fell outside expected limits.
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