Failure to Administer Hospice Morphine as Ordered: A resident on hospice with pneumonia and respiratory failure did not receive ordered Morphine for pain and SOB in a timely manner. Hospice documented worsening distress, including tachypnea, tachycardia, fever, lethargy, and labored breathing, while the MAR showed missed scheduled and PRN doses. Staff reported the medication was unavailable, did not verify EMD inventory before the doses were due, and did not notify the provider, even though the Morphine was later found in the facility's emergency supply and EMD inventory.
Failure to respond to resident chest pain and transfer request: A resident with HTN, prior TIA, and intact cognition told an RN he/she had chest pain and wanted to go to the hospital, but the RN did not contact the provider or call 911 after the resident walked away. The resident later left the building, was followed by staff, and EMS was eventually called after the resident reached an apartment complex and asked others to call 911. Hospital records showed chest pain with later dysarthria and right facial weakness, and the resident was admitted for suspected stroke.
A resident with peripheral neuropathy, impaired cognition, and a history of toe skin issues had ongoing redness and pain in multiple toes, but the record did not show timely provider notification or accurate skin assessment. Podiatry had recommended offloading the toe, yet the resident continued to report worsening pain and redness, and staff documentation was inconsistent about the condition of the toes. The NP was not notified until after surveyor observation, when new toe wound treatments and a podiatry consult were ordered.
A resident with HF and GERD had persistent nausea, vomiting, mouth sores, weight loss, and abdominal pain, along with abnormal BUN and creatinine results. The NP ordered GI and nephrology referrals and an abdominal US showed bilateral hydronephrosis and a renal cyst, but the consults were not scheduled and staff did not follow up despite ongoing symptoms. The resident was later hospitalized with renal failure.
Failure to document ordered PICC line measurements. A resident with a PICC line and a diagnosis including sepsis due to MSSA had physician orders for weekly dressing changes and for external catheter length and arm circumference measurements. The record showed incomplete and missing documentation of the ordered measurements, and the RN stated the measurements were completed but not documented in the TAR; the DON could not provide evidence that the measurements were done weekly as ordered.
Failure to Document and Report Skin Impairment: A resident with hemiplegia/hemiparesis, intact cognition, and dependence for personal care had a care plan and MD order for weekly skin checks, but the RN signed the check as completed without documenting findings. Surveyors observed reddened areas on the buttock and shin, and the resident reported untreated wounds and itching. The RN acknowledged seeing the skin impairment, applying lotion, and not notifying the UM or provider; the DON could not show the condition had been documented or treated before surveyor discovery.
A resident with a history of falls, cognitive impairment, and heart failure sustained unwitnessed falls with head injury, but the care plan was not revised, neuro checks were not documented after the head injury, and staff did not complete required post-fall monitoring per policy. The resident also had a DNR order, but staff could not promptly provide the Advance Directive to EMS, and CPR was initiated despite the DNR status.
The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with dementia and a percutaneous cholecystostomy drain, placed after gallbladder perforation and cholecystitis, had a physician order and care plan directing that the drainage bag be kept secure, drained to gravity, and monitored each shift per facility policy. Surveyors found that the drainage bag was instead pinned to the call light, which was attached to an elevated bed rail, preventing proper gravity drainage. An LPN reported observing this improper setup, and both the NP and DON stated the drain should not be attached to the call light; the DON was unable to provide evidence that the facility’s percutaneous drainage catheter management policy had been implemented.
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