A resident with dementia-related cognitive impairment and PRN pain medication orders was given edible marijuana by a former RN without a physician order. Another staff member observed the former RN cutting what appeared to be marijuana gummies into smaller pieces and placing them within the resident's reach, and the resident was later monitored after the incident.
A resident admitted with sepsis had an open coccyx lesion and redness noted on the skin inspection, but no orders or care instructions were in the chart. The resident stated the facility was supposed to continue treating the area after hospital transfer, yet staff were unaware of any current wound, and the RNCM confirmed no care orders were in place for the identified skin concern.
A resident receiving hospice and comfort care had no documented urinary output across multiple shifts, with no documented bladder scan, catheter check, or replacement despite the absent output; the resident was later hospitalized for urinary retention and the catheter was found out of place with 1250 ml of urine drained. In a separate case, a resident with HTN and a stroke history missed several scheduled doses of lisinopril because a CMA believed it should be held for low systolic BP, even though the order had no hold parameters.
Failure to administer medications per physician orders affected three residents. One resident did not receive ordered Seroquel and Xanax, another had Megestrol started late and Creon given at times not aligned with meals, and a third had a PRN Haldol order that was never transcribed to the MAR or administered despite documented agitation and confusion. Staff acknowledged the medication-order and MAR errors.
Failure to initiate wound care orders for a resident with recurrent abdominal blisters and a new open abdominal wound. The resident was cognitively intact and had care plan directions for weekly skin checks, daily skin inspections, photos of wounds, and documentation of wound treatment, but staff did not notify the provider when the new wound was identified, did not enter wound care orders at the time, and did not consistently apply InterDry. Staff also reported the resident had a dermatology referral for recurring blisters, but there was no scheduled derm appt or evidence treatment had started.
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.
A facility failed to administer meds as ordered and failed to notify the provider about repeated missed doses for two residents. One resident with dementia missed multiple doses of duloxetine, Eliquis, and olanzapine because she/he slept through morning med pass or refused care, and the chart showed no provider notification. Another resident with Parkinson’s disease and severe cognitive impairment missed repeated doses of carbidopa-levodopa due to sleeping or combativeness, with staff documenting the misses but not informing the physician until later.
The facility failed to follow and clarify physician orders for residents with dialysis needs, medication administration issues, and possible UTI symptoms. One resident with asthma, diabetes, edema, and later heart failure had a chest x-ray order that was not completed, another resident on dialysis had multiple meds held without documented orders to do so, and a third resident reported burning with urination but was not documented as being reported to the physician or monitored for a possible UTI; the resident was later hospitalized and diagnosed with a UTI.
A resident with hemiplegia/hemiparesis after CVA and recurrent UTIs had a physician order for a UA with reflex C&S due to dysuria, suprapubic discomfort, and urgency, but the urine sample was not collected promptly and lab results and new medication were delayed. The physician said the order was entered into the EHR and the RCM was to follow up, while the RCM was unsure what happened to the order and said the system did not prompt staff to collect the sample.
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.
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