A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
A resident with spinal conditions, a history of lumbar compression fracture, and documented ADL self-care deficits was care planned and Kardexed for two-person maximum assist transfers for bathing and wheelchair transfers. Despite this, a CNA transferred the resident alone multiple times between a recliner, wheelchair, and shower chair using only a gait belt, during which the resident reported the CNA was rough, fast, and caused pain. An LPN received the resident’s complaint that the CNA was not caring and was the only staff present, while another CNA and a regional clinical specialist confirmed that the Kardex required two-person assist and that the CNA had performed the transfers without assistance, in violation of the plan of care and facility expectations.
A resident with chronic kidney disease and a catheter experienced episodes of red and dark red urine, along with burning and back pain, over at least two days. The resident reported that a PT noticed the urine color change and that an RN had previously flushed the catheter when the urine was red, after which it cleared, but these observations and interventions were not documented. On a later day, a CNA and an LPN initially reported not noticing abnormal urine, and only after the CNA reported dark red urine did the LPN assess the resident and confirm hematuria and symptoms. Despite staff acknowledging that such changes should be documented per facility policy, there were no progress notes reflecting the hematuria or related catheter changes in the clinical record.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
A resident with severe cognitive impairment and major mobility limitations was ordered a customized wheelchair, but the DME process was not completed and follow-up was poorly documented. Staff and the resident’s daughter reported confusion about whether the order had been sent, and the DME company stated it had not received the needed documentation or proper coordination from the facility. Interviews showed the resident remained without the wheelchair despite repeated evaluations and attempts to clarify the order.
A resident with multiple comorbidities and incontinence was admitted without documented skin problems but was identified as at risk for pressure ulcers and ordered to receive frequent repositioning, barrier cream, weekly skin evaluations, and weekly Braden Scale assessments. Within days, CNAs, therapy staff, and nurses documented redness, rashes, open areas, and bleeding on the sacral/coccyx and perineal regions, while provider notes continued to describe the skin as warm and dry without wounds, and there was no evidence that early sacral redness and breakdown were promptly communicated to a provider. Required weekly skin assessments and Braden Scales were missed or incompletely documented, physician orders for barrier cream and repositioning were not consistently recorded as completed on the MAR/TAR, and detailed wound measurements and descriptors for MASD were delayed and backdated. Staff interviews confirmed that the resident experienced severe pain with pericare, that sacral skin was raw, red, and bleeding, that staffing shortages sometimes prevented turning and changing every two hours, and that documentation and communication about the MASD and sacral wound did not meet facility expectations or policy requirements.
A resident with testicular dysfunction had a physician order for Testosterone Cypionate 200 mg IM every 14 days, but facility records showed the injection was given once and then not again until more than two weeks later, with no documentation that the scheduled intermediate dose was administered or that the provider was notified of the missed dose. Nursing staff and leadership acknowledged that the testosterone injection due on a specific date was not given and that required notifications and documentation were not completed, despite facility expectations and pharmacy services policy. The resident reported opting to resume injections at a urology clinic due to concerns about inconsistent administration by facility staff.
A resident with sepsis, osteomyelitis, and a diabetic foot ulcer was discharged from the hospital on IV vancomycin to be given with HD on specific days. Facility staff entered orders to send the IV antibiotic to the HD center and documented in the care plan that IV ABX would be administered at HD, but did not coordinate with the HD center in advance to ensure the treatment could be provided under the center’s policies. The HD center, lacking required physician orders and unable to use medication brought in by the resident, did not administer vancomycin during two HD sessions. Facility documentation initially failed to reflect whether the doses were given or missed, with the MAR showing an "X" without an explanatory code and no timely progress notes. The DON and an LPN later acknowledged that two doses were missed, that communication and documentation were inadequate, and that the facility had no specific quality of care or coordination of care policy despite policies requiring accurate implementation of physician orders and complete charting.
An LPN prepared an incorrect dose of Buspirone for a resident by placing two 15 mg tablets into a medication cup instead of the ordered 15 mg dose (1/2 of a 30 mg tablet given twice daily). A surveyor questioned the order, prompting the LPN to re-check the EMR and recognize the discrepancy, after which one tablet was discarded. The LPN admitted she had misread the order and would have administered the wrong dose without the surveyor’s intervention, and the ADON confirmed that this would have been a medication error and not in accordance with the facility’s medication administration policy requiring adherence to prescriber orders and verification of the five rights.
A resident with multiple medical and psychiatric conditions, including epilepsy and recent seizure activity, was admitted with an advance directive and physician order specifying full code status and desire for CPR. On the day of the incident, the resident was last documented as well during morning rounds and later was found on the floor of his room, unresponsive and not breathing. Staff interviews, a 911 call transcript, and a police report showed that no CPR was in progress when the emergency call was made, no AED was brought to the room, and officers found the resident cold to the touch but without rigor mortis. The DON gave conflicting accounts about whether CPR was initiated, while other staff reported they did not see CPR performed, and there was no clinical documentation of CPR or AED use despite facility policy requiring immediate and continuous CPR/BLS for unresponsive full‑code individuals until EMS arrival. These actions and omissions resulted in the resident not receiving ordered life‑saving measures.
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