Failure to Follow Ordered Urology Consultation: A resident with urinary retention and a Foley catheter had a physician order for urology referral after a failed trial without catheter, but the consultation was not completed. An LPN knew the resident was supposed to be seen by urology but did not know why it had not happened, and the DON and ADON/IP stated the physician was expected to make the referral and that the status was not discussed in later monthly rounds.
A resident with COPD and a history of thrush received budesonide nebulizer treatments, but staff did not consistently rinse the nebulizer mask or instruct him to rinse his mouth after treatments. The resident reported that nurses or CMAs often left the room during treatments and that he was not told to rinse afterward, while the EMR showed budesonide orders that specifically instructed mouth rinsing to help prevent oral thrush. Staff interviews and the manufacturer's instructions showed the nebulizer chamber and face mask were to be cleaned after each use, but practice at the facility did not consistently follow those directions.
Staff failed to follow professional standards when a physician verbally instructed the DON to have nurses borrow a controlled medication (Lorazepam 0.5 mg) from one resident and administer it to another resident experiencing anxiety after other comfort measures failed. Because the ordered medication was not available on site, the pharmacy was closed, and the family declined ER transfer, an LPN removed a Lorazepam tablet from the first resident’s medication card and gave it to the second resident. This action bypassed facility policies requiring proper ordering, accountability, and use of controlled drugs only for the resident for whom they were prescribed, and the administrator, DON, and consultant pharmacist later acknowledged that borrowing medications between residents is not acceptable practice.
A resident received fast-acting insulin from an LPN before breakfast, and despite staff expectations that the resident would be awakened, have the meal tray set up, and eat within 20–30 minutes, observations later that morning showed the resident still asleep with an untouched tray and no documented blood glucose monitoring. In a separate case, another resident routinely wore bilateral compression stockings applied by staff for lower extremity edema, but review of the EMR and TAR showed no active MD order for the stockings despite prior related orders being discontinued, and the DON confirmed an order and treatment entry should have been present; the facility also lacked a policy for transcribing and communicating MD orders.
A resident experienced a fall in their room and was found on the floor on their side with a walker nearby. A CNA summoned a total body mechanical lift and sling, and an RN assessed the resident, noting unequal leg length and recognizing a likely hip fracture. Despite the suspected injury and the resident’s pain, staff placed a sling under the resident, changed a soiled brief, and used the mechanical lift to transfer the resident onto a medical cart, with documentation failing to clearly describe the transfer process. The DON reported that using a total body lift after falls, even with suspected injuries, was the facility’s usual process, while another RN with ED experience stated she would instead immobilize the area using a backboard and noted that most staff did not know how or where to obtain such equipment. The facility cited a nursing skills text as its professional standard, but staff interviews and the handling of this event showed inconsistent understanding and application of safe transfer practices for suspected fractures.
A resident with severe cognitive impairment and multiple neurological diagnoses was not consistently provided with a physician-ordered palm protector for contracture management. Despite documentation indicating the device was applied, observations showed the resident's hand was tightly contracted without the protector in place. Staff interviews revealed inconsistent application and lack of verification checks after transfers and meals, and no policy on following physician's orders was provided.
A resident with diabetes and orthostatic hypotension did not receive blood pressure medications according to physician-ordered parameters. Midodrine and Fludrocortisone were both administered outside of the specified blood pressure ranges, and low blood pressures were not promptly rechecked. CMAs involved were unaware of the facility's blood pressure policy, and required notifications and documentation were not completed as per facility protocols.
A resident who fell and hit her head did not receive consistent or complete neurological assessments as required by facility policy. Multiple neuro checks were missing critical documentation, including the Glasgow Coma Scale and pupil assessments, over several days. Staff interviews revealed unclear expectations and issues with the EMR system allowing incomplete entries to be marked as finished.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
The facility did not routinely complete Abnormal Involuntary Movement Scale (AIMS) assessments for residents prescribed antipsychotic medications, as confirmed by record reviews and staff interviews. Several residents with diagnoses such as schizophrenia, Alzheimer's disease, and dementia were receiving antipsychotic drugs without documented AIMS assessments, and staff acknowledged the absence of a policy or recent assessments for monitoring adverse side effects.
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