A facility failed to administer multiple ordered medications for two residents and failed to care plan an antipsychotic for one resident. One resident with diabetes, dementia, and depression had numerous daily meds not documented on the MAR, and another resident with spinal stenosis, CHF, HTN, bipolar disorder, diabetes, anxiety, and depression had several ordered meds not documented, including an antipsychotic; the care plan also did not address the antipsychotic. The DON stated residents should receive meds as ordered and that not documented meant it was not done, and the MDS Coordinator stated antipsychotics should be care planned.
Failure to assess and monitor surgical incision sites. A resident admitted with bilateral ankle ORIF had care plan interventions for monitoring surgical incisions for infection and changes in appearance, but the record showed the wounds were documented as unable to assess on initial skin checks. The resident was observed wearing walking boots and stated staff had not removed the dressings to assess the incisions, while an LPN said she had only checked circulation and had not visually seen the wounds. Interviews showed the treatment nurse knew of the surgical wounds but did not assess them, did not document the resident’s refusal, and did not notify the MD.
A CNA disconnected and flushed a resident’s PICC line even though PICC care was ordered for licensed nurses and was outside CNA scope. The resident had a PICC for infection-related treatment, and staff later described the line as not clamped with bleeding noted. RN staff, the LPN UCC, the interim DON, and the MD all confirmed that CNAs were not authorized or trained to perform PICC care.
Staff failed to follow diabetes management policies and provider orders for multiple residents by not consistently notifying the MD/NP of blood glucose (BG) readings outside ordered and policy-defined parameters and not documenting required treatment for hypoglycemia. One resident with Type 2 DM, severe cognitive impairment, and a high A1C had repeated episodes of severe hyperglycemia and hypoglycemia over several months, with numerous BG values above 400–500 mg/dL and below 70 mg/dL that were neither reported to the provider nor accompanied by documented administration of Glutose or glucagon. This resident later experienced altered mental status, hypotension, and a BG of 600 mg/dL, was transferred to the ED with a BG of 1025 mg/dL and diagnosed with DKA and related complications, and subsequently had a large acute to subacute cerebral infarct. Another resident on Lantus and Humalog sliding-scale insulin had multiple high and low BG readings, including values in the 40s and 50s mg/dL, without consistent documentation of hypoglycemia treatment or provider notification when thresholds were met. Similar unreported abnormal BG readings were found in other residents, leading surveyors to cite noncompliance with F684 for failure to provide appropriate treatment and care according to orders and resident needs.
Failure to Change Central Line Dressing as Ordered: A resident with a PICC and IV meds had a physician order for weekly central line dressing changes, but the MAR was initialed as if the dressing had been changed when staff later stated they had not done the dressing changes. The resident reported the dressing had not been changed since admission and showed a dressing still dated from admission; an LPN noted the dressing was overdue, and an RN later said she had accidentally initialed the MAR in error.
Failure to Perform Neuro Checks and Follow Fall Care Plan: A resident with a history of weakness, impaired gait, and high fall risk had repeated falls, including one with a forehead hematoma and another with facial and shoulder pain. The resident’s call light was found out of reach, required fall signage was not in the room, and the facility did not complete neuro checks after the falls. The DON confirmed the lack of neuro checks and the absence of a neuro check policy.
A resident with severe cognitive impairment, type 2 DM, CKD, and a history of falls had physician orders for blood glucose checks before meals and at bedtime and for sliding scale insulin aspart four times daily. Facility policy required verification of insulin orders, blood glucose monitoring per orders, and documentation of results and doses. However, after an NP attempted to edit the sliding scale order in the EHR, the order remained unsigned and inactive in the queue, preventing it from appearing on the MAR. Nursing staff did not identify that the insulin order was missing, resulting in multiple missed blood glucose checks and insulin doses over several days, despite the resident’s care plan directing staff to follow physician orders for diabetes management.
A resident with diagnoses including hemiplegia, depression, anxiety, and a fractured fibula had multiple ordered medications and skin treatments missed, including Nystatin powder, Aquaphor ointment, Skin Prep, and moisture barrier cream. The TAR showed several omitted doses across day, evening, and night shifts, and during wound care observation redness was noted to the right heel. The DON stated staff should administer medications as ordered by the Physician.
A resident admitted with UTI, Enterococcus faecalis bacteremia, and presumptive infective endocarditis had hospital and ID orders for IV ampicillin 2 g q4h to continue through a January stop date, but the Admission Nurse entered an incorrect December stop date into the facility’s system, which was then confirmed by an RN. The care plan and MAR reflected this erroneous end date, and IV ampicillin was administered only until mid-month, then stopped, resulting in 59 missed doses before the error was later discovered. A medication occurrence report cited omitted doses due to admission order and chart check errors, and leadership confirmed that staff and pharmacy failed to catch the discrepancy between the electronic order and the written hospital/ID orders.
Medication administration errors occurred when a nurse working with students gave a medication cup to a student and turned away while the student administered another resident’s medications to the wrong resident. One resident with dementia and chronic kidney disease received the roommate’s ordered meds in error, while another resident’s ordered meds were held on the MAR. The DON, ADON, and NP were notified, and the NP confirmed there was no negative outcome from the error.
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