Failure to Administer Ordered Anticonvulsant Medication: A resident with epilepsy returned from the hospital with instructions to resume oxcarbazepine, but the order was not entered into the EMR and the medication was not administered for an extended period. The ADON said she wanted clarification and claimed to contact the physician, but there was no documentation of physician communication, notification of the omission, or any medication error reporting in the record.
Failure to complete post-fall assessment and monitoring after an unwitnessed fall: A resident with dementia, Alzheimer’s disease, repeated falls, and impaired cognition was found on her knees beside her roommate’s bed by CNA staff. The LPN/RN assisted her back to bed, but staff did not complete a COC assessment, 72-hour monitoring, neuro checks, or document fall-prevention interventions, and the licensed nurse did not investigate how the resident got out of bed.
Missing Admission Skin Assessment After Surgical Re-admission: A resident returned to the facility after surgery for a left femur fracture and had three stapled wounds on the left hip and leg, but the skin reassessment was blank and no admission skin assessment could be found. RNs stated the surgical wound was not assessed on admission, and the DON noted that skin assessments are needed for newly admitted post-surgical residents to establish a baseline and assess for early signs of infection.
Psych Consult Not Completed as Ordered: A resident with major depressive disorder and schizophrenia had a psych consult ordered, but the consult was not completed as planned. The record showed the in-house psych provider asked for the reason for the referral, yet there was no documentation that the facility provided it. Later notes indicated the consult was denied due to insurance and DMH referral was requested, but there was no documentation that this referral or any further follow-up occurred.
Failure to follow up on surgeon and oncology referrals for a resident with left breast cancer and metastatic axillary lymph node disease. The DON could not locate documentation showing the referrals were scheduled, completed, or refused, and there was no record of family notification. An oncology consult later noted no records of complete cancer staging and that the oncologist did not know why the resident had not been referred for further evaluation or treatment.
A resident with schizophrenia, anxiety, and epilepsy left the facility after being observed agitated and pacing, and staff later found the resident missing during rounds. The AMA discharge process was not completed, with no documented physician notification, risk education, signed AMA form, discharge instructions, or confirmation that the resident understood the risks of leaving.
Failure to Notify MD of Arm Swelling and Discoloration A resident with a hx of a displaced R humerus fx, osteoporosis, and dementia developed swelling and discoloration of the R upper arm, but the physician was not clearly notified or informed of the change in condition. Documentation showed a VM was left, yet there was no record of the MD being told about the discoloration or of any response/order at that time. The resident later had an X-ray showing a displaced humeral fx and was transferred to acute care, while the facility had continued RNS and Hoyer lift-assisted care before the fracture was identified.
A resident with a fractured tibia and fibula was transferred by a CNA using a mechanical lift without the required second staff member. The resident reported being raised too high, not having her leg properly supported, and hitting her neck/head on the headboard with pain afterward. The record did not show documentation of the report, physician notification, or continued monitoring, and the LPN did not notify the MD after assessing no injury.
Failure to document a COC for IV fluids: A resident with poor oral intake had a new IV NS order entered, but the medical record did not show a COC report or 72-hour monitoring documentation. The LVN and DON both verified the missing documentation, and the DON acknowledged that the resident’s IV fluid order should have been tracked as a COC with monitoring to assess effectiveness.
A resident with severe cognitive impairment and bowel incontinence went 8 days without a BM being addressed in a timely manner, despite a bowel regimen and a care plan for constipation risk. Another cognitively intact resident had multiple OTC products at the bedside without a physician order or self-administration assessment, and staff stated the facility was not aware of the items. A third resident’s right arm sling was observed positioned incorrectly after a shoulder injury, and RN and CNA staff stated the sling was not providing proper support.
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