A resident with acute and chronic respiratory failure with hypercapnia returned from the hospital with discharge orders to continue nighttime BiPAP therapy with individualized settings, but no BiPAP order was initiated on readmission and there was no evidence the physician was contacted about this therapy. A subsequent order to follow up on BiPAP needs was documented as completed over multiple days, yet records show the resident did not receive BiPAP for 18 days. An LPN who worked the overnight shift throughout this period reported being unaware of the BiPAP requirement until the device was delivered by the oxygen vendor, and the Medical Director stated he would have expected the resident to receive BiPAP upon readmission.
A resident with hypertensive heart disease and CHF had physician orders for Amlodipine and Spironolactone that required BP checks before administration, including a hold parameter for low systolic BP. The MAR, BP summary reports, and progress notes showed no documented BP readings before Amlodipine for 31 of 31 opportunities and before Spironolactone for 41 of 42 opportunities, and an LPN and the DON acknowledged the ordered monitoring was not completed.
A cognitively intact resident with spinal stenosis and post-stroke hemiplegia/hemiparesis was discharged from the hospital with documented referrals to a spine center for evaluation and possible spinal steroid injections, which were reiterated in a later provider note citing ongoing lower extremity weakness. Despite these physician-ordered referrals and the resident’s repeated attempts to reach the appointment scheduler, the facility did not schedule or facilitate the neurosurgical consultation. The unit secretary, who was responsible for scheduling, reported being unaware of the referrals, and neither she nor the DON could provide any evidence that efforts were made to arrange the appointment, leading to a prolonged delay in the resident’s surgical follow-up.
A resident with a right thumb wound and brain damage diagnosis had a wound care order for cleansing, skin prep, calcium alginate with silver, and a foam dressing. During observation, an RN completed the dressing change but did not apply the calcium alginate with silver as ordered, and the RN acknowledged the omission. The DON stated the physician's order should have been followed.
A resident with dysphagia, autonomic dysfunction, seizure disorder, a G-tube, and dependence on staff for feeding had physician orders and a care plan requiring a minced and moist diet with thin liquids given by spoon only while upright. Video from a room camera showed a nurse providing thin liquids through a straw while the resident was lying down and continuing despite the resident coughing. Additionally, a physician ordered every-shift monitoring and documentation of vital signs, including lung sounds, O2 saturation, temperature, and signs of aspiration for seven days, but the MAR showed that required vital signs were not obtained on multiple shifts. The DON confirmed these deviations from physician orders and expected practice.
A resident with dementia and MS had a physician order for weekly skin assessments and a care plan identifying risk for pressure injury and skin breakdown due to incontinence and decreased mobility. The record did not show several ordered skin assessments were completed, and an RN stated the last assessment had been done weeks earlier; the DON could not provide evidence that the assessments were completed as ordered.
Surveyors found that the facility did not follow physician orders for lab monitoring for two residents. One resident with a history of acute pulmonary edema had an order for periodic BNP testing, but the scheduled BNP was not completed as documented on the MAR or elsewhere in the record, despite the resident reporting ongoing leg swelling. Another resident with hypertension had a physician order for a repeat BMP in one week, but there was no evidence in the record that this lab was obtained as ordered. These omissions show that physician-directed lab tests were not carried out as required.
The facility did not follow physician orders for scheduled weights and failed to implement its own reweigh policy for significant weight changes in two residents. One resident with hemiplegia, hemiparesis, and adult failure to thrive did not have monthly weights obtained as ordered, and multiple documented weight losses were not rechecked within the required timeframe. Another resident with type 2 DM experienced repeated large weight gains without any documented confirmation weights, despite facility policy requiring reweighs for substantial changes. The Dietitian and DON acknowledged that ordered weights and required reweights were not completed or could not be verified in the clinical record.
A resident with dementia and a documented tomato allergy consumed food with red tomato sauce and was subsequently ordered a one-time dose of Reglan 10 mg by a provider, with instructions for close monitoring for allergic reaction. The MAR showed the Reglan entry coded to refer to progress notes, where an LPN documented that the medication was pending pharmacy delivery, but there was no evidence that the dose was ever administered or that the provider was notified of the omission. A Pyxis inventory showed Reglan was routinely stocked, and in interviews the LPN confirmed the medication was not given and the DON stated she would have expected the medication to be administered as ordered and the provider notified and documentation completed if it was not.
Surveyors found that staff did not consistently follow physician orders or professional standards in several cases. A resident with dementia never had an ordered urine culture obtained, and there was no documentation that the provider was notified when staff were unable to collect the specimen. A resident with a suprapubic catheter, ordered for Enhanced Barrier Precautions, received personal care from a CNA who did not wear a gown despite posted EBP signage. Two residents experienced repeated missed or refused doses of ordered medications, including gabapentin, eye lubricants, and hydroxyzine, without evidence that a nurse or provider was notified or that the issues were addressed. Another resident on a fluid restriction for hyponatremia had orders that did not specify the allowed fluid amount, and the record showed that, although the MD was contacted about unclear limitations, the order was never clarified and staff could not state the specific restriction.
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