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.
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.
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.
A hospice resident with severe cognitive impairment, COPD, CHF, and a documented comfort‑focused care goal experienced unmanaged pain and terminal agitation when PRN morphine and lorazepam ordered for pain, SOB, and anxiety were not administered in a timely manner. A provider ordered sublingual morphine and lorazepam intensol early in the afternoon, and a hospice RN later documented that the resident was actively dying with severe pain, moaning, labored breathing, and terminal agitation, noting that pain management was ineffective and that the unit LPN was seeking an override for needed medications. MAR review showed morphine was not given until several hours after the order and after the hospice assessment, and lorazepam was delayed even longer, despite both drugs being available in the Omnicell and E‑Kit. In interviews, the LPN stated she did not feel the resident needed morphine and waited for a pharmacy code, and she did not consider the E‑Kit lorazepam, while the DON acknowledged the facility nurse was responsible for assessing and administering PRN medications and could not show that care met professional standards; a family member reported the resident appeared to be in agonizing pain and anxiety during this period.
Failure to notify the provider and monitor a resident’s lower-extremity blister and edema. A resident with DM, hypertensive heart disease, and dementia was observed with a blister on the right shin, black scabs, and bilateral leg edema, but the record lacked evidence that the MD was notified or that treatments/interventions were in place. An LPN and the unit manager were unaware of the findings, and the DON could not show that the facility knew about the wound until surveyor attention brought it to light.
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