A resident returned from the hospital after possible seizure activity with discharge instructions for neurosurgery follow-up, but the appointment was not scheduled and there was no record that the resident or representative declined it. In a separate issue, staff documented a foot cradle order as completed for another resident, yet surveyors observed the blankets resting on the resident’s legs and feet instead of being offloaded by the device, and staff acknowledged the order was not properly carried out.
Failure to follow enteral feeding positioning order: A resident with hemiplegia, hemiparesis, and gastrostomy status was observed receiving tube feeding while lying with the HOB less than 30 degrees and in a fetal position, despite a physician order to keep the resident elevated 30–45 degrees during feeding and for one hour after gravity feeds. An LPN acknowledged the HOB was not at the ordered height, and the DON confirmed staff were expected to consistently implement the order.
A resident with severe neuro deficits and limited L hip ROM sustained a closed L femoral fx after a PTA performed L hip rotational exercises that were not included in the PT plan of care. Facility review found the PTA did not follow the treatment directives, and surveyor interviews confirmed the plan lacked a directive for hip rotation and that a PTA should not independently interpret the plan.
A resident with severe cognitive impairment and a left breast nodule had a physician-ordered cancer center consult, but the appointment was not scheduled or completed. Another resident with a PICC line had missing admission documentation, no care plan for PICC care, and incomplete/tardy charting of dressing changes, external catheter length, and arm circumference measurements. Staff interviews confirmed the missed referral and the documentation gaps.
Midline catheter care was not documented as ordered for a resident admitted with sepsis due to enterococcus and pneumonia. Orders required dressing changes on admission and weekly, plus measurement of external catheter length and upper arm circumference on admission and weekly, but the TAR was signed off without supporting documentation. An RN said the measurements were done on 3rd shift, yet she could not locate the records, and the IP could not provide evidence that the dressing change or measurements were completed as ordered.
Failure to follow physician orders for wound care and weekly weights. A resident with DM and a skin picking disorder had a bordered gauze dressing over a skin tear, but staff acknowledged there was no treatment order for the wound. The same resident also had a physician order for weekly weights, yet several ordered weights were not obtained. The RD, RN, and DON all acknowledged the missed weights or could not provide evidence they were completed.
Failure to Notify Physician When Metoprolol Was Held: A resident with cardiomyopathy and atrial fibrillation had an order for metoprolol tartrate with instructions to hold for HR below 55 bpm and notify the physician. The MAR showed the medication was held multiple times for low or undocumented HR, but the record did not show physician notification, and an LPN and the DON could not find evidence that the physician had been notified.
Incorrect transcription and implementation of hospice medication orders. A resident with acute respiratory failure with hypoxia and HF was admitted to hospice and had physician-approved PRN orders for Levsin, Lorazepam Intensol, and Morphine Concentrate. The Levsin order was not transcribed or implemented, and the Lorazepam and Morphine orders were incorrectly entered as scheduled q1h meds instead of PRN; the MAR showed they were administered as scheduled meds, and an RN and the MD acknowledged the transcription errors.
A resident with DM received a rapid-acting insulin dose overnight after an incomplete order was transcribed as TID every shift instead of with meals. The insulin was given without a BG check or food intake, and the resident later developed severe hypoglycemia, was found unresponsive, and required transfer to the hospital.
Failure to Obtain Ordered Stool Specimens: A resident with functional diarrhea had worsening loose, watery stools and an NP ordered C. diff and fecal calprotectin stool tests for further workup. The record did not show the specimens were collected as ordered, and the NP was not notified for several days that the tests had not been obtained. The RIP acknowledged the tests were missed, and the DON stated she would have expected the samples to be obtained per the physician’s orders and the provider notified if they could not be obtained.
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Citations used to create this checklist
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