Missed physician-ordered daily weights were found for three residents with conditions including CHF, CKD/ESRD, dementia, and diabetes. Records showed repeated gaps in weight documentation across multiple days, despite orders for daily monitoring, and the DON verified the missed weights and stated they should have been identified.
A resident’s nephrology appointment was cancelled because required pre-appointment labs were not ordered or completed, and the DON later confirmed there was no evidence the provider was contacted to clarify the needed testing. In a separate event, another resident with severe cognitive impairment and multiple chronic conditions showed escalating distress, pain, hallucinations, and swallowing difficulty, but the provider was not notified until later and no other comfort measures or injectable meds were ordered before the resident was sent to the ER.
Failure to assess skin changes and complete ordered wound care: A resident with dementia and behavioral issues developed a skin tear and bruising to both arms, but weekly skin checks, bruising monitoring, and documentation were not completed, and protective sleeves were not in place. A second resident with diabetes, CVA-related weakness, and PVD did not receive ordered bilateral leg wound care when dressing supplies were unavailable, and the resident refused an alternate dressing because it felt tight.
Failure to Transcribe Telephone Orders: A resident with respiratory failure, COPD, and lung cancer had telephone orders from the MD for a chest x-ray, urinalysis, and CBC, but the orders were not transcribed into the medical record. The MD confirmed the orders were given, and the ADON verified she had not entered them. Facility policy required verbal telephone orders to be written and recorded in the chart.
Failure to respond to acute change in condition and wound deterioration: One resident with COPD, chronic respiratory failure, and diabetes developed respiratory distress, abdominal pain, and severe hypoxia, but reassessment and EMS transfer were delayed after the LPN documented low O2 sat and labored breathing. Another resident with recent abdominal surgery had an ordered stool specimen not completed after one attempt, and staff did not notify the MD when the abdominal wound became odorous and largely necrotic; the resident was later hospitalized with sepsis and an abdominal wall abscess.
A resident with a right lower leg skin tear had a physician order for daily cleansing and a band aid, but during observation the dressing removed was dated two days earlier. An RN verified the date and acknowledged she had worked the prior day and did not provide the ordered treatment. The resident had COPD, OA, CHF, anxiety, depression, and peripheral autonomic neuropathy, and had intact cognition with dependence for toileting hygiene, bed mobility, and transfers.
A resident with CAD, CHF, and CKD fell and later developed left arm pain, swelling, and decreased mobility. ED imaging showed a possible radial head fracture, and the resident returned with a sling and a note that orthopedics was to follow; however, the chart had no physician order for the sling and no evidence that an ortho consult was obtained.
Incomplete Assessment of Non-Pressure Skin Impairment: A resident with stroke-related weakness, DM2, CKD, COPD, anemia, and hidradenitis suppurativa had purple buttock areas and an open axillary area documented after returning from the hospital, but staff did not complete a comprehensive assessment of the skin impairment. A DON and LPN later reported no impairment or no awareness of the documented areas, while observation found buttock discoloration, a scabbed area, and pain with pressure; a wound NP later identified bilateral buttock abscesses related to hidradenitis suppurativa.
A resident with COPD and chronic respiratory failure asked to go to the hospital for worsening SOB, but the on-call provider ordered in-house monitoring and the resident was not told she could still request transfer; she later declined and was admitted with acute hypoxic respiratory failure and sepsis. The facility also did not start the bowel protocol for another resident with no BM for several days, did not coordinate hospice communication and records for multiple residents, and completed inaccurate skin assessments while missing transport and treatment issues for a resident with ongoing skin breakdown and rash.
A resident with a history of falls, weakness, and impaired transfers had an unwitnessed fall, but staff did not document a timely post-fall assessment or physician notification when she later developed worsening pain and loss of transfer ability. Nursing notes showed escalating pain, moaning with touch, swelling, bruising, and inability to stand/pivot, yet the x-ray was not ordered until the family requested it. Imaging then revealed an acute femoral neck fracture, and the resident was transferred for surgery; the surgeon later stated the fracture appeared to be at least 1 to 3 weeks old.
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