A resident with dementia and MS was admitted for respite care and was dependent on staff for eating and drinking. The care plan directed staff to encourage fluids, but intake records showed repeated low fluid intake over several days, and there was no documentation that the MD or resident representative was notified. The DON acknowledged the resident’s poor intake and progressive decline, and that no change of condition was sent per usual procedure.
Failure to Follow Wound Care and ACE Wrap Orders: A resident who had a femoral-tibial bypass and a right trans metatarsal amputation had hospital orders for dressing changes to leg incisions every other day, ACE wrap to the RLE, leg elevation, and OOB 2 to 3 times daily. MAR/TAR review showed no documentation that the dressing changes or ACE wrap were provided, and the resident stated the facility did not perform wound care after admission. The charge nurse and DON acknowledged the orders were unclear and that there was no documentation showing the ordered treatments were completed.
A resident recovering from a stroke with hemiparesis and dysphagia was receiving PT, OT, and SLP for mobility, ADL, and swallowing needs, but therapy was stopped after an insurance denial and the facility did not establish a restorative program while waiting on an appeal. Records showed the resident still had ongoing functional and swallowing limitations, remained on a modified diet with tube feeding, and staff gave conflicting accounts about the appeal status and continuation of skilled services.
Two residents did not receive showers/bathing as scheduled and preferred, with staff reporting shower aides were often pulled to the floor and showers were commonly reduced to about once weekly. In addition, an LPN/RCM confirmed that a trazodone dose increase approved by the in-house provider was not entered into the EHR, although a new naltrexone order was.
Missed Vital-Sign Checks During Change in Condition: Two residents had documented changes in condition, but staff did not complete timely, comprehensive VS assessments. One resident with DM and post-op care had stopped talking and was sent to the ER without a documented BG check at the time of decline; hospital records showed hypoglycemia. Another resident with respiratory risk developed SOB, wheezing, and low O2 sat, but the chart did not show a timely temp check; the ED later documented fever and acute hypoxemic respiratory failure.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident had repeated abnormal T and BP readings, including temperatures in the 80s F and BPs as low as 73/47 mmHg, but the CNA did not notify the RN and the RN did not notify the provider. Staff later stated the resident’s low vitals were not recognized as a change in condition, and the resident was eventually sent to the hospital for altered mental status and low BP, where EMS found hypothermia and the resident was admitted to the MICU.
Missing Orders for Suture Monitoring: A cognitively intact resident returned from the hospital after vascular intervention for dialysis access and was observed with three sutures in the left antecubital area. The EHR documented the sutures, but no physician or treatment orders were found for monitoring the sutures or the skin area, and both the RCM/LPN and CNO/RN stated such orders were expected.
A resident admitted after a fall with rib fractures and a PE developed an acute decline with snoring respirations, inability to awaken, and abnormal GCS findings. Staff monitored in-house for hours, obtained STAT labs, and delayed calling 911 despite persistent unresponsiveness and worsening neuro status. EMS later found the resident unconscious with decorticate posturing and unequal, non-reactive pupils; the resident was diagnosed with a large intracranial hemorrhage and herniation.
Missed Labs, Delayed Abnormal Lab Reporting, and Incomplete Neuro Checks: A resident with SIADH, cognitive impairment, and edema had an ordered BMP that was not obtained as scheduled, and abnormal BMP results were not documented as reported to the provider when received. The resident later had worsening electrolyte abnormalities. After a fall with forehead pain, neuro checks were started but several scheduled assessments were not completed, including the 8-hour and final 24-hour checks.
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