A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
A resident with urinary retention and an indwelling catheter had catheter care provided while a size 22 Fr catheter was in place, even though the physician’s order specified a size 20 Fr catheter. An LPN reviewed the order, confirmed the mismatch, and stated the needed catheter size was not available in facility supplies.
Failure to follow physician orders was identified for residents receiving insulin and BP medication. A resident with diabetes had low blood sugars documented without the ordered re-checks, and an LPN was observed priming insulin pens in a way that did not match the facility’s policy. A resident with HTN also received hydralazine on multiple occasions even though the systolic BP was below the ordered hold parameter.
A resident with Alzheimer’s disease and depression exhibited intermittent delusional statements, refusals of medications and care, and occasional yelling or suspiciousness toward staff over several months. Nursing notes documented these behaviors but did not show a comprehensive psychiatric assessment or evidence of a sustained major mood episode. A psychiatric NP subsequently added diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel, despite no prior history of schizoaffective disorder and no detailed evaluation in the record to support the new diagnosis. The resident’s representative reported no known mental health history or hospitalizations and was unaware of the schizoaffective disorder diagnosis, and the DON indicated there was no specific facility policy for schizoaffective disorder.
The facility failed to correctly administer insulin for a resident observed during insulin administration. An RN prepared a Humalog pen for a 2-unit dose based on the resident’s blood sugar, but did not prime the pen with 2 units before dialing in the dose and had to be corrected during the procedure. The DON was present, and the RN’s competency checklist later showed the priming step for the insulin pen.
A nurse failed to follow professional standards of medication administration when an LPN, who admitted to smoking marijuana before work, attempted to give a resident a blue pill later identified as finasteride 5 mg taken from another resident’s card, instead of the ordered famotidine 20 mg for GERD. The resident’s family noticed the discrepancy, questioned the pills in the cup, and retained a photo of the medication, which was confirmed through record review and drug references to be a drug not ordered for the resident. Facility records showed the resident was cognitively intact, had GERD, and had no orders for finasteride, while the facility’s own medication pass guidelines required verification of the correct drug against the MAR and prohibited borrowing medications, which were not followed in this incident.
The facility failed to follow medication orders and ensure proper medication administration for multiple residents. A resident with diabetes received Tresiba insulin doses despite blood glucose levels below the ordered hold parameter. Another resident with hypertension received amlodipine and lisinopril even when systolic BP readings were below the ordered threshold to hold the medications. In a separate event, a housekeeper found unidentified pills under a resident’s bed, and an LPN later reported that staff had been instructed to monitor that resident for pill pocketing and to watch all residents swallow their medications.
Staff failed to accurately carry out and document physician-ordered care for two residents. One resident with COPD and emphysema had a dirty oxygen concentrator and filter even though weekly cleaning was documented as completed on the MAR. Another resident with Parkinson’s disease, lymphedema, and pemphigus foliaceous had ordered Eucerin lotion and hydrocortisone ointment documented as given, but the resident said he had not received them, unopened ointment tubes were found in the treatment cart, and skin observation showed reddened, excoriated abdominal skin.
A CNA placed a PEG tube feeding on hold before repositioning a resident during a wound care observation, even though the Wound Nurse stated the CNA was not supposed to turn off or place the tube feeding on hold. The resident had stroke, dysphagia, and a PEG tube, was cognitively intact, and received most of his calories through enteral feeding.
A resident with a pressure ulcer and multiple comorbidities did not receive antibiotics and wound care as ordered by the physician, with missing documentation for several medication doses and treatments. Staff interviews revealed confusion about care plan requirements, and the resident was not consistently included on the assignment form for turning and repositioning, despite physician orders.
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