The facility failed to thoroughly assess and monitor multiple residents after injuries from altercations and to follow wound treatment orders. One resident with right hand pain and swelling after being struck by another resident had an x-ray showing a fractured metacarpal that was not reviewed for several days, and physician orders for a hand splint and ice were not implemented or documented, despite ongoing pain and visible swelling. Another resident punched in the head/face had no documented neuro checks or focused monitoring after the incident, even though a skull x-ray was obtained and the physician expected neuro assessments. Two additional residents with hand and toe wounds had physician-ordered daily wound care documented as completed on the TAR, but observations and resident reports showed dressings were not changed as ordered, wounds were left with unchanged or no dressings, and the DON was not informed of at least one new wound, contrary to facility wound care and intensive monitoring policies.
A resident with cellulitis, gangrene, and a necrotic left great toe did not receive wound care fully consistent with the wound care FNP’s documented plan of care. The FNP repeatedly ordered daily cleansing with hypochlorous acid, Betadine application, and calcium alginate dressings cut to fit inside the wound, with changes daily and as needed. However, nursing staff entered physician orders that reduced treatment to every other day and omitted or altered the calcium alginate directions, and these discrepancies persisted over multiple weeks. Interviews with LPNs, an RN, the FNP, the physician, the DON, and the Administrator showed that all expected the electronic orders to match the FNP’s recommendations, but they were unaware that the entered orders did not reflect the specialist’s specified frequency and application method, resulting in a failure to provide care per standards of practice and the certified wound care plan.
The facility failed to transcribe and implement physician orders, resulting in missed medication changes and laboratory testing for two residents. One resident with multiple conditions, including anemia, hypertension, seizure disorder, and bipolar disorder, had physician orders for routine labs, an autoimmune profile, initiation of doxycycline, discontinuation of lithium, and a lithium level check, but the EMR continued to show an active lithium order and lacked any entries for the new medication or labs. Another resident with diabetes and depression had physician orders for routine lab studies that were never entered or completed, and reported that no blood draw had occurred. Staff interviews showed that an LPN was unaware of the new orders, another LPN believed all new orders were sent to the DON for EMR entry, and the DON and Administrator both stated they were unaware that these physician orders had not been followed.
The facility failed to follow its falls protocol by not completing and documenting required neuro checks, fall evaluations, fall risk assessments, skin evaluations, and 72-hour incident follow-up (IFU) monitoring after multiple resident falls. In several cases, residents with significant cognitive and physical impairments fell, some hitting their heads and sustaining lacerations and fractures, yet neuro checks were either not done or not fully documented, and IFU notes were missing on multiple shifts over several days. These lapses occurred despite facility policy and leadership expectations that unwitnessed falls or head strikes trigger 72 hours of neuro checks and shift-by-shift IFU documentation.
A resident with significant GI history, chronic anemia, and recurrent constipation had physician orders and facility protocols requiring close bowel movement (BM) monitoring and a stepwise bowel regimen, as well as multiple medications for GI conditions, constipation, and other comorbidities. Staff failed to consistently document BMs, did not implement ordered bowel interventions when BMs were absent for several consecutive days, and delayed notifying the physician until the resident had gone multiple days without a BM and developed coffee‑ground emesis, leading to hospital evaluation where fecal impaction and stercoral colitis were documented. The care plan was not updated to reflect increased BM monitoring after a prior hospitalization for constipation/impaction, and the TAR showed missed documentation of ordered BM checks. In addition, the MAR showed repeated refusals of numerous medications throughout the month, including GI, cardiac, constipation, and psychiatric drugs, yet there was no documentation that the physician was notified of these frequent refusals, despite facility policy requiring reporting of medication refusals.
A resident admitted with chronic kidney disease, hepatorenal syndrome, and an existing implanted vascular access port did not have the port addressed in the admission assessment or care plan, and there were no physician orders for flushing, monitoring, or drawing blood from the port for an extended period. Despite multiple CBC and CMP lab orders, staff documentation did not reflect issues with lab collection until later, when IV fluids were ordered via the already accessed port and a monthly flush order was added, still without specific monitoring or blood-draw orders. In interviews, an LPN, an RN, the DON, and the ADON all acknowledged that implanted ports require physician orders and inclusion on the care plan, and that an RN accessed the port for blood draws after the lab was unable to obtain a sample, without a documented order to do so, confirming the facility’s failure to follow its own policies and standards of practice for implanted port management.
A resident with COPD, acute respiratory failure with hypoxia, and pneumonia had care plan interventions and physician orders requiring monitoring of respiratory status, oxygen saturation, and PRN oxygen at 2 L/min via nasal cannula for O2 saturation below 90% and/or wheezing and shortness of air. For an entire month, the MAR showed no documentation of oxygen administration or O2 saturation checks, and an oxygen saturation summary showed only two assessments over several months. The resident, who was cognitively intact, reported repeated pneumonia episodes, nighttime shortness of air, and that staff did not check O2 saturation, and there was no oxygen equipment in the room despite an active PRN order. Interviews with an RN, CMTs, CNAs, an LPN, and the Administrator/DON revealed inconsistent understanding of responsibilities, lack of awareness of the resident’s respiratory and oxygen orders, gaps in documentation, and a practice of obtaining vitals only monthly, resulting in failure to follow the ordered respiratory monitoring and PRN oxygen therapy.
A resident with COPD, chronic respiratory failure, and sleep apnea had an order for nightly CPAP with oxygen, but staff did not apply the CPAP for an extended period after the mask broke, despite a facility policy requiring immediate replacement of malfunctioning equipment. Nursing notes documented that the mask was missing or broken and that staff were awaiting replacement parts, while the treatment record repeatedly showed CPAP was not applied. During this time, the resident developed lethargy, anxiety, lower-than-normal oxygen saturation, and later was found with significantly decreased oxygen saturation and abnormal coloration, leading to transfer to the hospital, where hypercapnia was documented and linked to the lack of CPAP use. Staff interviews revealed that multiple LPNs knew the mask was broken but did not notify the physician, and there was no timely physician notification when the resident’s condition changed, despite expectations from the DON and Administrator that such changes and equipment failures be reported.
A resident with cognitive impairment, stroke-related weakness, and mobility issues fell while attempting to get into bed and was returned to bed with a mechanical lift, but no thorough post-fall assessment was documented and the fall was not added to the care plan. Over the next several days, CNAs and therapy staff observed non-verbal signs of pain and leg swelling, and the family reported hip/leg pain, yet nursing documentation showed incomplete assessments, pain scores of 0, and no administration of ordered PRN acetaminophen. A mobile x-ray was ordered but delayed, and the resident was not sent to the hospital when the x-ray could not be obtained as planned; when imaging was finally completed, it revealed an acute right hip fracture, confirming that the facility failed to provide timely follow-up care and pain management after the fall.
The facility failed to consistently assess, document, and obtain appropriate treatment orders for wounds and orthotic use for three residents. One resident returned from the hospital with a forehead laceration and a prescribed wrist splint, but the care plan was not updated, a wound assessment was delayed for several days, there were no early orders to monitor the laceration or skin under the splint, and staff were confused about which arm required the splint, with observations showing the splint off and not monitored. Another resident with chronic leg ulcers had an active wound treatment order, yet MARs showed missed treatments, multiple weekly skin assessments documented skin as intact with no treatment in place, no wound assessments were available for an entire month, and observations revealed multiple open areas on the leg being treated under a single order, with dressings applied in a way that left an open area partially uncovered and adhesive on the wound bed. A third resident, care planned as at risk for skin breakdown, had a weekly skin assessment charted as intact and no nurse notes for several days, while CNAs reported a prior skin tear on the forearm that had been treated with steri-strips and bandages and had progressed to multiple scabbed areas with redness; the DON later confirmed there had been no earlier documentation or timely physician notification for treatment or monitoring orders.
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