The facility failed to follow physician orders for post-fall care for three anticoagulated residents who experienced falls. One resident on a blood thinner with a head injury was ordered to be transferred to the ED after a telehealth evaluation, but an LPN did not send the resident, citing instructions to contact a supervisor first and inability to reach that supervisor. For two other residents on anticoagulants, providers ordered intensive neuro checks (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but staff instead performed neuro checks only once per shift for 72 hours. The DON and Medical Director acknowledged that the transfer and monitoring orders were not implemented as written.
A resident with dementia and a hearing deficit did not receive ear care as ordered because the chart lacked the Debrox order and the ear was flushed before the intended Debrox course was completed. In a separate incident, staff witnessed inappropriate kissing of a resident with dementia, but the allegation was not reported to the provider and the care plan was not updated. A third resident’s wound care was also not completed as ordered when an RN used normal saline instead of the prescribed Vashe wound wash.
A resident with dementia and a percutaneous cholecystostomy drain, placed after gallbladder perforation and cholecystitis, had a physician order and care plan directing that the drainage bag be kept secure, drained to gravity, and monitored each shift per facility policy. Surveyors found that the drainage bag was instead pinned to the call light, which was attached to an elevated bed rail, preventing proper gravity drainage. An LPN reported observing this improper setup, and both the NP and DON stated the drain should not be attached to the call light; the DON was unable to provide evidence that the facility’s percutaneous drainage catheter management policy had been implemented.
A hospice resident with severe cognitive impairment, COPD, CHF, and a documented comfort‑focused care goal experienced unmanaged pain and terminal agitation when PRN morphine and lorazepam ordered for pain, SOB, and anxiety were not administered in a timely manner. A provider ordered sublingual morphine and lorazepam intensol early in the afternoon, and a hospice RN later documented that the resident was actively dying with severe pain, moaning, labored breathing, and terminal agitation, noting that pain management was ineffective and that the unit LPN was seeking an override for needed medications. MAR review showed morphine was not given until several hours after the order and after the hospice assessment, and lorazepam was delayed even longer, despite both drugs being available in the Omnicell and E‑Kit. In interviews, the LPN stated she did not feel the resident needed morphine and waited for a pharmacy code, and she did not consider the E‑Kit lorazepam, while the DON acknowledged the facility nurse was responsible for assessing and administering PRN medications and could not show that care met professional standards; a family member reported the resident appeared to be in agonizing pain and anxiety during this period.
Failure to notify the provider and monitor a resident’s lower-extremity blister and edema. A resident with DM, hypertensive heart disease, and dementia was observed with a blister on the right shin, black scabs, and bilateral leg edema, but the record lacked evidence that the MD was notified or that treatments/interventions were in place. An LPN and the unit manager were unaware of the findings, and the DON could not show that the facility knew about the wound until surveyor attention brought it to light.
Failure to follow surgeon’s wound vac order: A resident with a surgical back wound was ordered to continue NPWT, and the surgeon later changed the setting to 75 mmHg continuous. Staff did not report the updated order to the physician, and surveyors observed the wound vac still set at 125 mmHg until it was changed after surveyor intervention.
A resident with a PICC line and IV antibiotics did not have confirmed catheter tip placement in the SVC before the line was used, and the record showed repeated antibiotic administration without that verification. PICC dressing changes were also documented without required external length and arm circumference measurements, and when the catheter was later charted as migrated 6 cm, the provider was not notified; the DON and physician both stated they expected placement confirmation and notification of migration.
A resident with a UTI and an order for IV Meropenem every eight hours did not receive three scheduled doses, and there was no evidence the provider was notified of the missed antibiotics. The resident, who was on 1 L O2 via nasal cannula, later exhibited confusion, removal of the nasal cannula, shortness of breath, and decreased O2 saturation requiring an increase to 4 L O2, but the night RN did not document these findings, did not recognize them as a change in condition, and did not notify a provider. Oncoming staff then found the resident with decreased alertness, tachycardia, and continued increased O2 needs, notified the NP, and arranged transfer to the ED via non-medical transport rather than EMS, despite altered mental status and hypoxia. Hospital records documented arrival with altered mental status, severe hypoxia, hypercarbic hypoxic respiratory failure, sepsis, and influenza, and the resident expired later that day; the Medical Director and family interviews confirmed expectations and misunderstandings regarding antibiotic administration, change-in-condition reporting, and the choice of non-medical transport.
A resident with dementia, post-stroke hemiplegia, severe cognitive impairment, and documented weight loss had physician orders and a care plan for 1:1 feeding assistance and Glucerna 237 cc PO three times daily. Surveyors observed the resident seated in a wheelchair with the right arm strapped to the chair, attempting unsuccessfully to self-feed while staff only set up the meal and did not provide 1:1 assistance until prompted. The assigned RN was unaware of the 1:1 feeding order. Later, the resident was observed unable to lift a cup containing the ordered Glucerna supplement, and the med tech assisted with intake only after the surveyor intervened. The DNS confirmed her expectation that staff should have provided 1:1 meal assistance and ensured supplement administration as ordered.
Surveyors found that two residents receiving chemotherapy via PICC lines did not receive care in accordance with physician orders, facility policy, and professional standards. For one resident, a PICC with a baseline external length of 0 cm had a dressing change documented, but the required external length measurement was left blank; during an observed dressing change, an LPN measured the external length as 1 cm and acknowledged it had not been previously documented. For the second resident, the PICC dressing was not changed on admission and was delayed for nine days, and there was no documentation that the external catheter length was measured as ordered. The NP stated she expected timely dressing changes and external length measurements, and the DON could not provide evidence that these tasks were completed and documented until surveyors raised the concern.
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