Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Two residents experienced lapses in care when staff failed to follow physician orders and facility procedures. A resident with diabetes received daily glipizide but had blood sugars checked only during the first week after admission, despite several days of nausea, vomiting, poor PO intake, and meal refusals, and was later hospitalized with documented hypoglycemia attributed to glipizide and no PO intake. Another resident with peripheral arterial disease, diabetes, and moderate cognitive impairment developed a large, facility-acquired skin tear on the arm, but the record contained only an initial wound summary with no treatment orders, no investigation into how the injury occurred, and no documented communication with the resident or family, even though family involvement in care discussions was identified as very important.
Facility nurses did not follow PRN bowel care orders for two residents who went multiple days without a BM, failing to give MOM on the ordered day four. Nurses also initialed off on q-shift edema monitoring for a resident with renal insufficiency and diuretic use, but did not document whether edema was present, where it was located, or its extent.
A resident with severe cognitive impairment had CBC and BMP labs ordered, but the BMP could not be resulted because the specimen had mild hemolysis and interference was noted. An LPN and the DON/RN stated the hemolysis should have been reported to the provider, and the DON/RN said the BMP should have been redrawn.
A resident with diabetes, bilateral BKAs, and CKD was started on buprenorphine-naloxone for pain after an outside provider ordered 0.5 film SL q12h, but an RN incorrectly entered the order as 1 full film q12h without a second-nurse verification. An alert order directed staff to monitor for adverse effects and to stop the medication and notify the provider for severe nausea, confusion, disorientation, or other significant symptoms. After the first dose, the resident developed moderate to severe N/V, increasing sedation, and unusually loud snoring, with multiple CNAs noting the resident was very drowsy, difficult to arouse, and not acting as usual, and meal trays remained untouched. The RN, on only their second shift, gave a borrowed antiemetic without a standing order, repositioned the resident several times, and checked blood sugars and gave insulin, but did not contact a provider despite the MAR instructions. Short staffing and unadjusted assignments contributed to CNAs not reporting their concerns to the nurse. Later that day, a CNA found the resident unresponsive and not breathing, leading to initiation of CPR and subsequent notification of the provider and leadership about the unexpected death and the medication error.
Two residents admitted for rehab services, both alert and oriented per their 5-day MDS, were repeatedly addressed by an LPN using terms such as "honey" and "love" instead of their given names. Neither resident had been asked about name preferences; one stated she preferred not to be called "honey," and the other stated she usually goes by her birth name. The LPN reported a habit of using endearing names and was unaware of any policy or professional standard requiring use of residents' preferred names, while the administrator later stated staff should address residents by their preferred names.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
The facility failed to coordinate ordered follow-up and wound care services for two residents. One resident with a fracture and UTI reported waiting for an ortho appt for days, while staff said the referral fax was not received and the appt was not scheduled until later, with the resident notified only shortly before the visit. Another resident with a pressure ulcer did not have the ordered alternating pressure mattress in place, and the wound vac was delayed after the wound clinic order; staff said they had trouble obtaining the device and did not document provider communications.
Failure to monitor skin changes and manage bowel meds: One resident with cognitive decline, poor circulation, and limited ROM had a weekly skin check order, but staff observed painful redness on the foot during care and the area was not documented on the skin assessment. A second resident who was dependent for care, always incontinent of bowel, tube fed, and had an open full-thickness coccyx wound had repeated loose stools, yet scheduled constipation meds were still given on those days despite care plan directions to monitor diarrhea and keep skin clean and dry.
A newly admitted hospice resident arrived restless, non-verbal, and repeatedly attempting to get out of bed, yet staff did not obtain vital signs, perform an admission nursing or skin assessment, complete a pain assessment, or develop a baseline care plan. RNs and CNAs reported placing the bed against a wall, using pillows and a floor mattress, and assigning staff to sit with the resident due to agitation and fall risk, but there was no documentation of 1:1 monitoring, consent for bed positioning, or details of care provided and the resident’s response. The electronic record contained only a brief nursing note describing restlessness and the hospice nurse’s involvement leading to transfer back to the hospital, and medical records staff confirmed no additional documentation existed, which the DON acknowledged did not meet expectations for new admissions.
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