Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
Quality of care was not provided according to orders for two residents. One resident had an order for Omnicycle restorative therapy 6 days per week, but several scheduled sessions were marked as not completed or refused. Another resident had an order for valproic acid levels every 6 months, but the required lab monitoring was not obtained, and the DON confirmed the test was missed.
A resident had Acetaminophen listed on the allergy record, yet an order was entered for PRN Acetaminophen for pain and doses were administered on multiple occasions. The resident’s MRR did not identify Acetaminophen as an adverse consequence, and the DON verified the medication had been given without the facility or pharmacist identifying the potential adverse consequence.
Failure to Document Meal Intake and Insulin Administration: A resident with type 1 DM and hyperglycemia had an order for Insulin Aspart after meals with dosing based on blood sugar and meal intake. The MAR showed multiple meal-time insulin administrations where the amount of food eaten and the number of units given were not documented, and the DON confirmed the missing documentation.
Failure to follow ordered oxygen settings. A resident was observed receiving oxygen via nasal cannula at 4 L/min even though the active MD order directed 2 L/min. An LPN confirmed the oxygen was set above the ordered rate, and the DON stated that any increase would require documentation of a change in condition and updated MD orders, which were not present in the record.
A facility failed to follow physician orders for two residents. One resident with CVA and inability to use a standard call bell was found with a regular thumb-press call light instead of the ordered Geri call cord after a room change, and staff said the call light had not been moved. Another resident on hospice had an active Q2 turn-and-reposition order, but the chart had no documentation that the care was completed, and a CNA said there was no specific place where it was documented.
Staff failed to ensure appropriate supervision for an incapacitated resident during off-site urology appointments. Records showed the resident had been determined incapacitated and was dependent on staff for ADLs, and a prior visit had resulted in the resident becoming very upset and agitated, after which the urology provider instructed that the resident should not attend appointments alone. Despite this, the resident was transported by the facility van and left in the waiting room without facility staff present, while the van driver waited in the parking lot and family presence was inconsistent. A urology office receptionist confirmed that the resident had been alone in the waiting room on multiple occasions, nonverbal and appearing very sad.
The facility failed to administer RSV vaccines to two residents even though consent had already been obtained from their health care decision makers and the vaccines were addressed under facility policy and CDC/ACIP guidance. During record review, the DON confirmed both residents should have received the RSV immunization by the time of survey review but did not know why it had not been given.
Failure to follow ordered care and treatments for multiple residents. A resident with dysphagia orders was left unsupervised with food despite 1:1 feed assist and meal supervision orders, another resident had no documentation that ordered splints were applied and removed with skin checks, and a third resident’s tube feeding was observed running at a rate different from the physician order, with the DON confirming the discrepancy.
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