A resident with pressure injuries had duplicate wound treatment orders for the same site, and an RN documented a wound treatment as completed in the eTAR before actually performing it. Another resident with DM had no care plan focuses or interventions for diabetes, and although a BG of 473 was treated with Humalog per sliding scale, there was no documentation that the physician or NP was notified as ordered.
A resident with multiple comorbidities, including recent pneumonia, thrombocytopenia risk, and renal issues, had weekly CBC/BMP labs ordered. One set of labs showed a critically low platelet count and significantly worsened renal function. The overnight LPN received the critical values and sent a text to the physician instead of establishing direct voice contact, then later texted about another resident. The physician only saw and responded to the second text and stated he never saw the message about the critical platelet count. No direct call was made, no new orders were obtained, and the critical results were not effectively communicated for approximately three days. The issue came to light when the resident’s representative questioned the labs during a care plan meeting, prompting a unit manager to call the physician, who then reviewed the results and ordered transfer to the ER. Interviews and policy review showed that facility expectations and protocols required emergent, direct phone communication and escalation for critical labs, which did not occur in this case, resulting in delayed care and treatment.
A resident with sepsis, COPD, type 2 DM, and CHF experienced a reported change in condition when family told an LPN the resident "looked septic." The LPN notified the RN supervisor, who assessed the resident and obtained vitals, including a blood sugar of 438 mg/dL, but there was no documentation that sliding-scale insulin was administered per existing orders or that repeat vitals were fully recorded after the concern was raised. The RN supervisor did not document her assessment findings, and there was no record of the time the MD was notified or any orders received regarding the hyperglycemia, contrary to facility policy and job expectations for assessment and documentation of significant changes in condition.
A resident with a history of stroke, right hemi craniotomy, left-sided weakness, epilepsy, severe cognitive impairment, and ongoing headaches and dizziness was ordered to follow up with Neurology/Neurosurgery. The resident, dependent on staff for dressing and requiring an interpreter, reported anticipating the appointment and stated no one came to prepare them, and that they did not refuse. Staff interviews and record review showed that the appointment scheduling and communication process relied on a unit clerk, an LPN, and a whiteboard, but December appointment records were not retained, the CNA was not informed to get the resident ready, and there was no documentation of refusal, missed appointment, physician notification, or rescheduling. Physician notes recommending neurology follow-up and documenting headaches and dizziness were not visible in the facility’s eMR until after surveyor inquiry, and the facility lacked a formal policy for scheduling resident appointments.
A resident with dementia and communication deficits experienced an unwitnessed fall and complained of left leg pain while found on the floor partially supported by a chair. An LPN documented no visible injury, noted repeated refusals of pain medication, assisted the resident to bed, and did not return to reassess, later stating they needed to complete a med pass and did not inform the physician of the pain complaint, assuming it was due to chronic arthritis. Neurological flow sheets for the post-fall period contained multiple blanks and incomplete entries for level of consciousness, movement, and staff initials. The DON confirmed that required post-injury monitoring, pain assessment, and direct provider notification were not carried out as expected under facility policies, and the resident was later sent to the hospital for evaluation of left hip pain and a femur fracture.
Two residents with significant skin integrity concerns did not receive timely assessment, documentation, or initiation of care plans and wound care orders as required by facility policy and professional standards. Delays in care plan initiation and documentation, as well as missed physician orders, resulted in inadequate management of pressure injuries and wounds.
A resident with dementia and diabetes, who was at risk for nutritional problems, did not receive a physician-ordered Ensure Plus supplement at the scheduled time because it was not available on the medication cart. Staff interviews confirmed the supplement was not administered as ordered due to stocking issues, and the DON stated staff are expected to follow physician orders.
A resident sustained burns after spilling heated tea on their arm and abdomen during breakfast. Although immediate care was provided and the physician was notified, the LPN did not enter the physician's wound care order into the EHR or document the treatment as administered for two days. The incident was also not documented in the progress notes on the day it occurred, contrary to facility policy. The DON confirmed these documentation failures, resulting in incomplete medical records for the resident.
A resident admitted for IV antibiotic therapy for osteomyelitis did not receive four consecutive doses of prescribed Cefazolin due to medication unavailability and IV access issues. Facility staff did not document timely notification to the physician about the missed doses, and the medical record lacked evidence of physician awareness or alternative orders during the period of missed therapy.
A resident with multiple chronic conditions and diabetic foot ulcers did not receive care in accordance with professional standards when repeated recommendations from the wound care consultant for physician follow-up, including consideration of antibiotics and a bone scan, were not documented as communicated to or acted upon by the primary physician. Nursing staff noted changes in the wound's condition, but there was no evidence of required physician notification or follow-up in the medical record, contrary to facility policy.
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