A resident with paraplegia, chronic pain, impaired cognition, and anticoagulant use fell from bed during wound care preparation and complained of pain in her right knee, hand, and elbow. X-rays later showed a nondisplaced distal femur fracture, but the result was texted to the NP instead of being phoned to the on-call provider after hours, no new orders were obtained before the nurse left, and the resident was not sent to the ER until the next day.
A resident with DM and a stage 4 pressure ulcer to the right heel did not receive documented ordered wound care on multiple occasions. The care plan and physician orders called for cleansing with NS, applying calcium alginate and a dry dressing, plus pressure-relieving measures and wound-healing supplements. Facility records showed repeated gaps in the WAR/TAR, and staff interviews indicated the wound care may not have been completed or documented as ordered.
Incomplete post-fall monitoring and documentation: A resident with severe cognitive impairment, fall risk, and multiple orthopedic and neurologic diagnoses had an unwitnessed fall with pain and later bruising, but nursing staff did not consistently assess, monitor, communicate, or document the event across shifts. Interviews showed one nurse did not receive report or complete an assessment, another forgot to document the fall, and the DON and UM acknowledged missing documentation and communication.
A resident with Alzheimer’s disease and dependent mobility had ordered Geri-sleeves not in place during observation, with bruising on both arms and open skin tears on both legs. Staff linked the leg wounds to the resident’s wheelchair footrest and noted she had been transferred and moved in the wheelchair without adequate protection from the metal parts. The resident’s wound dressings were also found off, and staff stated the wounds should have remained covered per orders to prevent infection.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
Failure to Place Ordered Gauze Roll in Left Hand: A severely cognitively impaired resident with CHF, Alzheimer's disease, depression, and muscle wasting had a physician order for a gauze roll to the left hand for prophylactic treatment and daily monitoring. Although the TAR was signed as completed by an LVN, surveyors observed the resident's left hand closed and no gauze roll in place, and an LVN and CNA confirmed the hand roll was not present. The DON and ADM stated the ordered hand roll should have been in place as ordered.
A facility failed to provide ordered ostomy, trach, and bowel supplies for two residents. One resident with a urostomy was given colostomy bags instead of the correct urostomy bags, so the family purchased the proper supplies. Another resident with a trach and neurogenic bowel did not receive ordered inner cannulas or Enemeez, and the family had to buy those items after the facility lacked the needed supplies. Staff, including the CSC, DON, and ADM, acknowledged the facility was responsible for providing the ordered items.
A resident with a pacemaker, AFib, and CHF had an unplugged pacemaker monitor found on the floor of her room while she was away. The DON stated the monitor should be plugged in at all times and that residents with pacemakers needed to be transmitted via monitor, but staff did not know why it was unplugged and had not reported any related concerns to the PCP.
A resident with ESRD on dialysis and a confirmed UTI/E. coli infection did not receive ordered antibiotics as documented. After labs and a urine culture were obtained, the NP ordered Blujepa, then later changed the order to Invanz IV, but the MAR showed no documentation that either antibiotic was administered. Nursing notes also lacked documentation of medication delivery status or follow-up with the pharmacy or provider. The resident later became lethargic and hypotensive at dialysis, was sent to the hospital with septic shock, and later expired.
Missing Orders and Care Plans for Cervical Collars Two residents admitted with cervical fractures wore cervical collars, but the facility had no physician orders or care plan interventions for collar management, care, or skin monitoring for several days after admission/readmission. Staff interviews showed CNAs had no instructions for collar care, an LPN briefly removed one resident’s collar without an order, and the charge nurse confirmed neither resident had collar orders. Hospital paperwork indicated the collars were to remain on at all times and included hygiene instructions, but those directions were not reflected in the facility record.
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