A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
A resident with MRSA, chronic venous insufficiency, and left lower extremity vascular ulcers did not receive ordered wound treatment after returning from the hospital. The discharge summary directed specific LLE wound care, but the admission orders and TAR did not include the treatment for about a week. Staff interviews confirmed the wound order was missed during admission and that the required review/audit process was not completed.
A resident admitted for subacute care with multiple diagnoses, including UTI and diabetes, had physician progress notes documenting plans for a repeat UA/CS and initiation of low-dose Lantus insulin, but these intended orders were never transcribed into the electronic physician order system or reflected on the MAR. Review of the record showed no active orders or administration for the repeat UA/CS or Lantus, and no nursing documentation of contacting the physician to clarify the progress note entries. Interviews with the physician, unit manager, nursing supervisor, and DON confirmed that the physician typically enters orders directly into PCC or gives verbal orders to nursing, that the physician likely missed entering these specific orders, and that leadership was unaware that the intended treatments documented in the progress notes had not been converted into active orders or carried out.
Failure to identify and monitor a skin alteration: A resident with CHF, morbid obesity, muscle weakness, and venous insufficiency had intact cognition but was dependent on staff for ADLs and at risk for skin breakdown. Staff observed scab-like areas, dry patches, and a small open area on the lower leg, yet the skin check did not identify the change and the record lacked documented treatment or a monitoring plan. CNA staff said the areas were present the day before and nursing staff were aware, while the UM said she was not aware until informed by the CNA.
A resident with cerebral palsy, dysphagia, and cognitive communication disorder developed a new open area on the buttock/coccyx, but the wound was not seen by the wound MD until about 12 days later. Nursing documented the open area and used a dressing initially, yet no initial treatment orders were implemented before the wound MD visit. Staff interviews confirmed that initial wound orders are normally used until the wound MD sees the resident, but they did not know why this resident was not seen sooner or why orders were not started.
A resident with dementia, mobility impairment, and dependence on staff for ADLs sustained an acute distal femur fracture after staff failed to follow the care plan and facility policy requiring gait belt use during transfers. The resident’s records showed a need for assisted transfers and ambulation, yet multiple CNAs reported lifting and stand-pivot transferring the resident from bed and wheelchair without gait belts on several occasions, including the last transfer before a bruise and swelling were noted on the resident’s knee. An assessment and x-ray subsequently confirmed the fracture, and the ADON’s investigation concluded the injury most likely occurred during a chair-to-bed transfer performed without a gait belt.
A resident with multiple complex medical conditions did not receive a physician-ordered antibiotic in a timely manner after developing a new area of redness and swelling. Although the medication was available on-site, the first dose was delayed by 14 hours due to a nursing supervisor's misunderstanding of administration timing, contrary to facility policy and physician expectations.
A resident with dementia and other chronic conditions developed a coccyx wound that was not assessed by the Wound Nurse Practitioner for three weeks after initial nursing documentation. The same resident sustained a clavicle fracture after a fall, and hospital discharge orders for a sling, non-weightbearing status, and arm monitoring were not implemented or documented by nursing staff. Interviews confirmed staff were unaware of the required care and the DON expected these interventions to be carried out and recorded.
A resident with multiple complex diagnoses was readmitted after hospitalization for GI bleed and new onset atrial fibrillation, with discharge instructions requiring follow-up with Cardiology and GI providers within one week. Despite physician orders and documentation in the discharge summary, staff failed to schedule these appointments, and interviews revealed that key personnel were unaware of the requirement, resulting in the deficiency.
A resident with severe cognitive impairment, high fall risk, and on anticoagulant therapy experienced an unwitnessed fall and was unable to communicate details of the incident. Despite facility protocol requiring neurological assessments after unwitnessed falls, nursing staff did not initiate or document these assessments, relying instead on a roommate's statement that no head strike occurred. Leadership interviews confirmed the expectation for such assessments, but none were performed or recorded.
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