A resident with ESRD on hemodialysis, CHF, COPD, and chronic respiratory failure had physician orders for daily, later weekly, weights to monitor CHF, but staff repeatedly failed to obtain weights as ordered and did not document reasons for missed weights or refusals. Over multiple weeks, weight records showed large, unexplained fluctuations, including gains of 20–25 lbs and a same-day difference of nearly 60 lbs, without same-day reweighs or documented verification of accuracy. Nursing staff and CNAs obtained and recorded weights on posted lists, but significant discrepancies were entered into the record without review of prior values, and the Unit Manager and DON were not notified of these changes, despite the resident’s need for accurate weight monitoring.
The deficiency involves the facility’s failure to provide physician-ordered wound treatments to two residents on weekend day shifts when the wound care nurse was not present. One resident with a recent below-the-knee amputation had orders and a care plan for daily dressing changes and monitoring, but the Treatment Administration Record showed no documentation for two consecutive weekend days; the assigned agency nurse stated she was not informed she was responsible for wound care, and a family member reported bleeding on the sheets and an inability to get the dressing replaced. Another resident with bilateral lower extremity lymphedema and a care plan for pressure ulcer risk had daily orders for Xeroform, abdominal pads, Kerlix, and ace wraps to both legs, but the Treatment Administration Record showed a missed treatment on a weekend day; the assigned nurse, who reported being new and not skilled at wrapping legs, confirmed the treatment was not completed, and the resident verified the treatment was not received. The DON stated that nurses assigned to the hall are expected to complete ordered treatments on weekends.
A resident with diabetes and a history of basal cell carcinoma developed an itchy scalp lesion that was treated with topical medications per NP orders, but an ordered dermatology consult was never completed. Although the NP documented from the outset that dermatology should evaluate the lesion and later noted the resident’s repeated inquiries about the consult, no appointment was scheduled. A nurse signed off the dermatology order as completed, yet the transportation staff member who later assumed appointment‑scheduling duties was unaware of the need for the visit and could not find a referral. The dermatology clinic reported it had requested additional information from a former appointment scheduler and never received a response, and facility leadership could not verify that the dermatology appointment had ever been arranged.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
A resident admitted for rehab after an exploratory laparotomy with new colostomy had a hospital discharge order for twice-daily wet-to-dry NS dressings to a 4 cm abdominal wound with seropurulent drainage, but this order was not transcribed onto the physician orders or TAR. The admitting nurse reviewed the discharge summary only for medications, and the DON skimmed the summary and later forgot to recheck for incision care orders, resulting in no wound treatment being set up. Subsequent nurses assessed the incision but did not provide wound care, and the PA later stated that staff should have read the entire discharge summary and contacted him if no incision orders were found.
A resident with dementia, gait abnormalities, and a history of falls was found on the floor in front of a wheelchair and assessed by an RN, who documented no pain or injury and returned the resident to a wheelchair. The RN entered the event in the EMR as an injury rather than a fall, did not complete required fall risk and post‑fall evaluations, and did not report the fall in shift report, so management and the primary provider were not promptly notified and automated fall protocols were not triggered. Over subsequent days, the resident repeatedly complained of right leg pain with documented pain scores and received PRN analgesics while outside imaging orders were delayed and not clearly communicated to the NP. When the NP later assessed the resident for persistent discomfort and limited ROM, a hip/pelvis x‑ray and then a CT scan were ordered, ultimately revealing multiple right hip and pelvic fractures. Interviews and record review showed that the fall was not disclosed to the NP or family until after the CT results and internal investigation, demonstrating a breakdown in communication, documentation, and interdisciplinary coordination around the resident’s fall and subsequent pain complaints.
A resident with multiple comorbidities and severely impaired cognition experienced two falls in one day. After the second fall, an RN assessed new left leg pain and obtained a STAT order for x‑rays of the left hip and femur, but the mobile x‑ray was not completed that night due to access issues and lack of staff response. The next morning, the resident’s representative reported the resident was in pain and requested Tylenol before dialysis; an RN performed a limited assessment, relied on the prior evaluation and pending STAT x‑ray, and allowed the resident to attend dialysis, while the DON, seeing the resident laughing in a wheelchair, did not assess pain. When the x‑ray technician arrived later, the resident was already at dialysis, and the exam was again delayed. Dialysis documentation showed ongoing left lower extremity pain and early termination of treatment, and the resident was later found to have a hip fracture requiring surgery. The deficiency centers on the failure to ensure timely completion of the ordered STAT x‑ray and prompt diagnostic evaluation of the resident’s post‑fall leg pain.
A resident on Eliquis for DVT prevention, with multiple comorbidities and a care plan identifying bleeding risk, sustained a left lower leg injury when a NA pulled her wheelchair backward and her leg struck a damaged bed footboard. The resident immediately reported 10/10 pain and significant bleeding; the NA’s towels became saturated before an RN applied pressure for about five minutes and placed a pressure dressing, documented the wound as a small skin tear, held the anticoagulant, and did not initiate EMS or hospital transfer. The DON did not assess the wound and accepted the report that bleeding was controlled, while the Medical Director was not informed of the mechanism of injury or the full extent of bleeding. The resident later contacted her RP, who observed blood on the dressing and called 911; EMS found the resident in severe pain with elevated BP and HR, and the ED identified a large hematoma and difficulty controlling bleeding at the facility. During hospitalization, the resident developed acute blood loss anemia requiring transfusion and surgical evacuation of a 16.2 cm hematoma with debridement and wound VAC placement, leading to prolonged wound care and ongoing pain management after return to the facility. Surveyors cited the facility for failing to adequately assess the injury, consider anticoagulant-related bleeding risk, and promptly initiate emergency medical intervention, resulting in Immediate Jeopardy for the resident.
A resident with a history of subdural hemorrhage, prior fractures, diabetes, and gait instability fell after using the call light for toileting assistance that was not answered, then attempted to ambulate alone and fell. Night-shift staff found the resident on the floor, noted a pain response when moving the leg, but did not complete or document a post-fall assessment or notify the provider, and the fall was not properly reported to the next shift. On the following shift, nursing staff did not perform or document a comprehensive assessment despite repeated reports of severe right hip pain (up to 10/10) from the resident, CNAs, a med aide, and therapy staff, and vital signs entries showing high pain scores. The UM eventually assessed the resident, obtained a verbal stat order for a right hip x-ray, but called the mobile imaging provider instead of entering the order into the required electronic system, causing delay in imaging. When imaging was finally completed and the provider notified, the resident was sent to the hospital, where a comminuted, displaced, impacted right hip fracture was confirmed and surgical repair was performed at a secondary hospital.
A resident with high-risk prostate cancer, cognitively intact and dependent on staff for ADLs, had a scheduled oncology appointment for labs and a Lupron injection that was missed when a transportation aide could not take him due to a CPR class and another aide could not accommodate the trip. The appointment was rescheduled about a month later without notifying the DON or clinical team, and there was no documentation in the medical record about the missed appointment. The resident reported receiving Lupron every six months for years, expressed concern about the delay in treatment, and oncology later documented he was slightly overdue for his next dose.
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