A resident with stage IV colon cancer, hepatic metastases, and an ileostomy had a newly placed biliary drain that was ordered to be flushed daily with sterile saline. Facility staff documented the drain as not used or capped, stated there were no orders in the chart, and did not flush it for about a week despite the family reporting the need for daily flushing and the hospital discharge instructions specifying it.
A resident with CHF, renal failure, and dementia showed clear changes in condition, including lethargy, clammy skin, poor intake, and reduced speech, but nurses did not promptly assess, document, or notify the MD/NP. Staff later found him in respiratory distress with low O2 sat, fever, tachycardia, and hypotension; he was sent to the ER in cardiac/respiratory failure and died.
A resident with nephrostomy tubes did not receive ordered dressing changes and site assessments as directed by the provider. The wound nurse said she only changed the dressing once, while RN A and an LVN each believed the other was responsible for the care. The resident and family reported the dressings were still labeled from an earlier date when the resident went to the ED for pain, and imaging showed one nephrostomy tube was no longer in place.
A resident with moderate cognitive impairment, fall risk, and impaired mobility sustained a nasal fracture after an unwitnessed fall and was discharged from the hospital with an ENT follow-up order in 7 days. Facility records showed the ENT appointment was not scheduled until later and was not documented in the resident’s chart when expected. The unit clerk said he wrote the appointment on his calendar, while the DON and MD stated follow-up orders were expected to be scheduled and documented in the clinical record.
A resident with Parkinson’s disease, cognitive decline, and CHF returned from the hospital after AKI, pneumonia, dehydration, and SOB, but the facility did not ensure the physician or NP followed the discharge order for follow-up within one week. The record showed no physician progress note after the return, and interviews with the physician, NP, resident, and staff confirmed the follow-up did not occur as expected.
A resident with dementia, osteoporosis, rheumatoid arthritis, and a history of falls slipped from her wheelchair in the dining room and was left without timely assessment or treatment. Staff did not promptly document the fall, notify the RP, or complete a full post-fall evaluation, and the resident remained in the facility for over 24 hours before x-rays revealed a hip fracture that required hospital transfer and surgery.
A resident with hemiplegia and vascular dementia was admitted for respite care with no documented skin issues, though she was at risk for skin breakdown. During the stay, family reported the resident was found with dried fecal matter on her back and perineal area, a dirty sheet under a clean pad, and new open areas on her bottom; an LVN later described small open, blistered areas and moisture-related skin damage. Staff stated the resident had no skin issues on admission, but the DON and Administrator said they learned of the concerns only after the family complained.
Missing CHF Orders for Fluid Restriction and Daily Weights: A resident with CHF, CKD, and dementia returned from the hospital with discharge instructions for a 2000 mL/day fluid restriction and daily weights, but the facility’s physician orders did not include those directions. Nursing documentation showed weights were recorded only intermittently, and daily skilled notes did not reflect daily weight assessment or ongoing documentation of fluid intake as expected for the resident’s CHF care.
Undated and Unsigned Wound Dressing: A resident with dementia, severe cognitive impairment, and pressure ulcers had a wound dressing on the left plantar foot found not dated and not initialed during observation. The RN and DON stated that facility policy required wound dressings to be dated and signed, and the resident’s physician order and care plan directed ongoing wound treatment for the pressure ulcer.
A resident with a right foot fracture was observed wearing an orthopedic boot, but the chart lacked a physician order and the care plan had no focuses, goals, or interventions for the boot. The charge nurse and ADON both acknowledged the missing order and care plan, even though the resident had been admitted post-hospitalization with a camboot and the boot was being used daily to immobilize the fracture.
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