A resident with multiple medical conditions, including encephalopathy and anemia, had a physician order for Megestrol Suspension as an appetite stimulant to be given twice daily within specific time windows. During a morning med pass, an RN administered several medications but omitted the ordered Megestrol, later confirming it remained in the med cart and that the order had not been followed, despite facility policy requiring adherence to physician orders. In a separate case, a newly admitted resident with encephalopathy, multiple sclerosis, epilepsy, and dementia had hospital discharge instructions for a Neurology follow-up within one to two weeks, but the facility did not arrange this appointment, even though the admissions process requires reviewing discharge summaries and setting up needed follow-up care.
Failure to document and carry out CHF-related orders occurred for a resident with CHF, NSTEMI, pleural effusions, AFib, and CKD. The resident had no HF care plan or documented HF goals, a 1500 mL fluid restriction was not clearly tracked, a six-pound weight gain was not reported to the provider, and intake/output was not documented. IV fluids were ordered for dehydration, but there was no documentation that they were given or why they were not started, and a chest pain episode with lethargy and SOB was not documented in the EMR.
A resident with a G-tube and functional quadriplegia had repeated tube dislodgements that led to hospital transfers, and the physician order for tube care did not include instructions to prevent displacement; on observation, no abdominal binder was in place. Another resident with lymphedema and chronic venous stasis ulcers was observed wearing compression devices with severe leg pain, but the record lacked a physician order and wearing schedule for the compression device, and staff and the DON confirmed the management orders were not in place.
A resident with dementia, Alzheimer's disease, and CKD had conflicting code status documentation: a physician order listed DNR while the POLST listed Full Code and noted the resident lacked decisional capacity. The UM confirmed the mismatch and could not determine the correct code status, while the SSD found no documented family discussion about code status since admission and the DON stated the physician order should correspond with the POLST.
A resident with plagiocephaly and other complex diagnoses was observed wearing a cranial helmet, but the physician order for 23-hour wear with a daily one-hour removal and cleaning was not properly carried out or documented. The e-MAR remained blank, daily nursing assessments did not show the required removal and cleaning tasks, and the DON confirmed nursing was responsible for following the order while the POC record only reflected helmet cleaning.
A resident with multiple diagnoses did not have monthly weights documented for three consecutive months, despite physician orders and facility policy requiring this monitoring. Staff interviews confirmed that CNAs had not consistently obtained weights, leading to gaps in care planning and delayed interventions.
Nursing staff did not document physician notification, change in condition, or nursing interventions for a resident who developed a high fever, despite facility policy requiring such actions. The resident, with a history of respiratory illness and pneumonia, had a temperature of 102.9°F recorded, but no further temperature checks or interventions were documented for over 15 hours. Interviews with LPNs, CNAs, an RN, and the DON confirmed that standard practice would have included prompt notification, interventions, and documentation, none of which occurred in this case.
A resident with intellectual disabilities and dementia, who was prone to scratching and picking at their skin, did not receive consistent care to address these behaviors. Although interventions such as hydroxyzine and geri sleeves were ordered, staff relied on observing the resident's actions to administer PRN medication, despite the resident's inability to request it. Ongoing skin injuries and bleeding were documented, and staff expressed uncertainty about the appropriateness of PRN orders for this resident.
A resident receiving hospice care for a malignant brain neoplasm did not have required hospice nurse progress notes consistently placed in their hospice binder, despite weekly visits. Facility staff, including the RN and DON, confirmed that these notes were necessary for ongoing care coordination and were expected to be reviewed during weekly IDT meetings, but the absence of documentation was not identified or addressed.
A resident with a history of respiratory failure and an ingrown toenail developed a blackened area on the right great toe after a podiatry procedure. Despite reporting the issue and associated pain to multiple staff, the concern was not promptly communicated to the wound care team as required by facility protocol. A CNA observed the impairment and informed an LPN, but the wound care team was not notified until later, and required documentation was not completed, resulting in delayed intervention.
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