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 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.
A resident receiving IV antibiotics for a UTI caused by an ESBL-producing organism did not have a physician's order for isolation precautions, as required by facility policy. The care plan indicated contact precautions should be in place, but review and staff interview confirmed the necessary order was not obtained.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required by their care plan.
The facility failed to follow physician orders for a urology referral after a resident's stent placement and did not obtain or document an order for PEG site care for another resident. Nursing staff and the DON confirmed that required referrals and orders were not completed or documented, and care plans were not updated to reflect changes in resident status.
A resident with multiple medical conditions was given her roommate's medications after an LPN failed to properly verify her identity and medication details, despite the resident questioning the number of pills. The error was discovered after administration, and the resident experienced no adverse effects.
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