A resident with colitis and renal dialysis dependence did not receive ordered hydrocortisone enemas after hospital discharge because the medication was not available, and MAR review showed multiple missed doses. The resident reported worsening rectal pain, appeared pale and weak, and was later rehospitalized after hospital records noted a relapse of symptoms that improved once the steroid enemas were started. The facility also missed ordered Veltassa doses after a later discharge despite a critically elevated K+ level, and staff acknowledged the medication was not administered because it had not been delivered by the pharmacy.
Failure to Follow Ordered Behavior Monitoring: Two residents, including one with Alzheimer's disease and anxiety disorder and another with dementia with agitation, had physician orders for every-shift monitoring of mood, behavior, and agitation with documentation of the number of occurrences and interventions used. Review of the MARs and records did not show the required documentation, and the DON could not provide evidence that the ordered monitoring had been completed.
Improper Unna Boot Application: A resident with fluid overload had an order for an Unna boot to the RLE, but nursing staff applied the dressing incorrectly by stopping above the ankle and omitting the foot and ankle. The resident reported increased pain, and a NP video consult documented acute R ankle pain, ankle edema, and serous drainage; an RN and the DON acknowledged the Unna boot was not applied correctly.
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.
Failure to follow physician orders affected three residents. One resident’s wound dressing was not changed daily as ordered, with an LPN signing the TAR as completed despite not doing the treatment. Another resident had significant weight loss, but the ordered Remeron for appetite stimulation was not initiated and the RP was not notified as expected. A third resident was repeatedly observed in bed without ordered bilateral seizure pads, and an RN signed the TAR as if the pads were in place when they were not.
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.
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