Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
Failure to Document Meal Intake and Insulin Administration: A resident with type 1 DM and hyperglycemia had an order for Insulin Aspart after meals with dosing based on blood sugar and meal intake. The MAR showed multiple meal-time insulin administrations where the amount of food eaten and the number of units given were not documented, and the DON confirmed the missing documentation.
Staff failed to ensure appropriate supervision for an incapacitated resident during off-site urology appointments. Records showed the resident had been determined incapacitated and was dependent on staff for ADLs, and a prior visit had resulted in the resident becoming very upset and agitated, after which the urology provider instructed that the resident should not attend appointments alone. Despite this, the resident was transported by the facility van and left in the waiting room without facility staff present, while the van driver waited in the parking lot and family presence was inconsistent. A urology office receptionist confirmed that the resident had been alone in the waiting room on multiple occasions, nonverbal and appearing very sad.
A resident readmitted with a pulmonary embolism was ordered apixaban and ibuprofen, a high‑risk combination identified in facility policy as potentially causing serious GI bleeding. When the orders were entered into PCC, a moderate drug–drug interaction alert warned that ibuprofen may enhance the anticoagulant effect of apixaban, and the ADON signed off on the alert without documented prescriber justification of benefit over risk or evidence of enhanced monitoring. Over the following days, nursing notes described the resident becoming very weak, refusing meals and fluids, and developing hematuria and possible rectal bleeding while still receiving both medications; a nurse asked the physician about holding ibuprofen, but there was no documented response. The resident later had a gross amount of blood in the brief consistent with a GI bleed, was sent to the ER, and was found to have a GI bleed with a drop in hemoglobin, demonstrating failure to follow the facility’s medication monitoring and adverse consequence prevention policy.
A resident with DM had physician orders for twice-daily fingerstick blood glucose checks, multiple scheduled insulin glargine doses, a daily HumaLOG dose, and a hypoglycemia protocol. On one day, there was no documentation of blood glucose monitoring in the vitals, MAR, or progress notes, and no evidence that any insulin was administered. In an interview, the DON and Administrator confirmed the resident did not receive the ordered fingersticks or insulin, resulting in a failure to provide medications in a timely manner as ordered.
A resident with documented decision-making capacity had a POST and care plan specifying full code status and full interventions, including CPR and life-sustaining treatments. As the resident’s condition declined, with increasing weakness, poor intake, low blood pressure, and a nonhealing coccyx wound, the PA reconfirmed that the resident understood her prognosis and still chose to remain full code with heroic measures. Later, when the resident became unresponsive with abnormal vital signs and respiratory difficulty, staff and the physician attempted to reach the resident’s son to change the POST to DNR instead of immediately implementing the existing full code orders, and they continued to monitor and document rather than initiate full interventions until the family reported the resident was unresponsive, at which point an LPN began CPR and EMS took over. In interview, the DON and ADON acknowledged they knew the POST specified full code and that the resident’s directive was not followed.
A resident with cerebral palsy, autism, a PEG tube, and an NPO order was given a cola by a staff member unfamiliar with the resident, after the resident requested the drink. The resident, who had moderate cognitive impairment and had been determined incapacitated, drank the cola and immediately coughed, and the episode was documented as a choking event. Review of records showed other residents had orders for nectar- and honey-thick liquids, and the facility acknowledged that a CNA provided the cola without checking the Kardex and diet orders. Subsequent staff interviews showed that staff could describe the need to verify diet orders or involve nursing before providing food or drink, but prior training materials did not explicitly address checking and following physician diet orders before giving residents any food or fluids.
A resident receiving enteral nutrition had tube feeding equipment at bedside that was not dated as required by physician orders and standard nursing care. Staff confirmed that the syringe and graduate, used for feeding and flushes, should be dated daily and replaced every 24 hours, but this was not done. The DON acknowledged the omission.
Two residents experienced deficiencies related to incomplete and inaccurate medical records. One resident had blood pressures taken from a restricted arm despite a physician's order, and another resident's blood sugar checks and insulin administration were not documented as required. The DON confirmed these lapses in care and documentation.
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