Multiple residents did not receive care according to physician orders and care plans. One resident with complex medical and psychiatric conditions had an ordered weekly skin assessment missed, and later was found with a widespread red, moist, painful rash that the representative had been treating independently with Nystatin powder, which was not on the MAR. Another resident on Sertraline for depression had required every-shift behavior and side-effect monitoring incompletely documented over several months, and multiple doses of the antidepressant were not administered as ordered. A third resident on antipsychotic and antidepressant therapy had required every-shift behavior and side-effect monitoring that was frequently not recorded. Additionally, a resident with Parkinson’s disease and diabetes went five days without a bowel movement, and the ordered stepwise bowel protocol, including PRN laxatives and enemas after three days without a BM, was not implemented.
Two residents did not receive care according to physician orders and professional standards. One resident with a history of fracture and schizophrenia had albuterol and fluticasone inhalers kept at the bedside, which staff reportedly allowed due to delays in reaching the room, despite no physician order or self-administration assessment documented in the record. Another resident with a blood clot and depression was found with ordered Sage boots off and placed on a chair, even though the medical record required bilateral use at all times with refusals documented, and there was no record of refusal on the day observed; both an LPN and the DON acknowledged the boots should have been in use.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
A resident with type 1 DM, partial left-side paralysis, and ataxia after a stroke was observed with glucose tablets on his desk and reported taking them whenever he felt his blood sugar going low. A physician note referenced the resident taking glucose tablets when blood sugars were in the 60s, but a review of current physician orders showed no active order for glucose tablets, which was confirmed by the CRN and DON.
Two residents experienced deficiencies in care when physician orders and facility protocols were not followed. One resident with Parkinson's disease and chronic kidney disease went more than four days between documented BMs without bowel protocol medications being administered or physician notification documented, despite standing orders outlining stepwise interventions. Another resident with interstitial lung disease and heart failure had a PICC line with an undated, loose dressing and unsecured tubing, and nursing staff could not locate current orders for the line after IV antibiotic therapy had ended, nor confirm whether it should still be in use or removed.
A resident with multiple comorbidities, including UTI, diabetes, heart failure, and CKD, experienced a significant change in condition characterized by somnolence, poor oral intake, and possible sepsis. Nursing staff sent an SBAR to the physician reporting the change and requesting further evaluation and treatment, and later sent a second SBAR noting ongoing lethargy, congestion, and refusal of medications and food, and asking for an exam, labs, or a portable CXR. The resident was later found catatonic and unresponsive and was sent to the ER after the physician was called. There was no documentation of any physician communication or response between the initial and subsequent SBARs, and facility leadership confirmed there was no record of a response to the first SBAR.
A resident with multiple chronic conditions had standing PRN orders for a bowel protocol, including Senna, Bisacodyl (oral and suppository), and a Fleet enema, to be used based on specific time intervals without a BM and to notify the MD if there was no response. Record review showed the resident went more than five days without a BM, with no documentation that the ordered bowel medications were administered during part of this period and no documentation that the physician was contacted after more than 96 hours without a BM. The ED acknowledged that nursing staff should have notified the physician and did not.
Multiple residents did not receive ordered or care-planned interventions, including one resident with a fall history who was left sitting on the bed edge and subsequently fell, after which ordered orthostatic BP monitoring was not documented; another resident with muscle weakness and malnutrition who had physician-ordered pressure-relieving boots was repeatedly observed in common areas without the boots on; a resident with psychiatric diagnoses had an elevated BP that was not reassessed or further evaluated; and a resident with cardiac and swallowing issues had an ordered carrot splint for the right hand that was not applied despite observations of tightly fisted hands and fingertip pressure marks on the palm.
The facility failed to follow its bowel protocol and PRN constipation orders for two residents who went more than 72 hours without a documented BM. Standing orders required stepwise use of bisacodyl delayed-release tablets, bisacodyl suppositories, and Fleet enemas when no BM occurred in three consecutive days, with provider notification if there was no response. For one resident with a fracture and history of falls, only daily MiraLax was given while ordered bisacodyl tablets, suppositories, and enemas were not administered during multiple 3–4 day gaps without a BM. For another resident with cellulitis and pulmonary fibrosis, only a single bisacodyl tablet dose was given, and the ordered suppository and enema were not used despite prolonged periods without a BM. The DNS acknowledged that these residents had no documented BM for over 72 hours without the required nursing interventions.
Surveyors found that staff failed to follow professional standards for bowel care for two residents who went more than 72 hours without a BM. One resident with psychosis and dementia had a 96-hour gap between documented BMs; although Docusate was ordered and given BID, there was no documentation that the physician was notified after 72 hours without a BM, and the MDS RN confirmed staff should have contacted the physician but did not. Another resident with atrial fibrillation and hypertension had an 87-hour gap between BMs, with PRN orders for Milk of Magnesia, Bisacodyl suppository, and Docusate for constipation, yet there was no documentation that any of these PRN bowel medications were administered during that period.
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