A cognitively impaired resident slipped while being showered by a CNA, who reported catching the resident and did not initially observe a head impact. Another CNA assisted with transfers and later, along with the first CNA, noticed a small amount of blood on the resident’s head while grooming in the room and notified an LPN. The LPN observed minimal bleeding and sent the resident to the hospital, where the resident received staples for a head laceration. Facility documentation later indicated the resident had exhibited behaviors during the shower and bumped the head on the shower room wall, causing a laceration. Despite a facility policy requiring structured neuro checks for 72 hours after any head injury, the ADON confirmed that neurological assessments were not performed because the resident was sent to the hospital and were not initiated when the resident returned the same day.
A resident with a history of falls, recent femur fracture, moderate cognitive impairment, and dependence for ADLs fell while attempting to transfer independently from bed to a wheelchair while wearing slippers, despite a care plan requiring assisted ambulation and fall-prevention measures. A CNA found the resident on the floor, assisted her up, and took her to the nurse’s station without obtaining an RN/LPN assessment and did not report the fall, even though the resident complained of wrist pain. An X‑ray later showed an acute distal radius and ulnar styloid fracture, and the resident returned from the hospital with a soft cast and an order for urgent orthopedic follow‑up. The facility failed to ensure the orthopedic referral was completed: the orthopedic office could not reach the facility using an incorrect phone number, no appointment was scheduled, the transportation aide received no appointment request, and there was no EMR documentation of follow‑up, leaving the resident in a loose, misshapen soft cast until a delayed ortho visit resulted in application of a hard cast.
A resident experienced a fall and subsequently complained of significant left hip pain, with pain scores escalating from 7/10 to 10/10 and documented difficulty with bed mobility. An NP ordered a STAT hip X-ray after the resident refused range of motion due to pain, but the RN initially entered it as a routine order and later changed it to STAT. Despite the facility’s policy that STAT imaging be completed within four hours and that nursing follow up with the radiology provider and notify the MD/NP if delays occurred, there was no documentation that the MD was notified of the resident’s worsening pain or that the incomplete X-ray was escalated that day. The X-ray was not performed until the next day, when another RN noticed it had not been done and contacted the X-ray company, and imaging then revealed an acute intertrochanteric femur fracture.
Multiple residents did not receive their scheduled 9:00 a.m. medications within the required one-hour window, and an IV medication bag was left hanging at a bedside without any label indicating when it was hung or who administered it. Around midday, several cognitively intact or moderately impaired residents reported they had not yet received their morning medications, which included opioids, antipsychotics, anticonvulsants, antihypertensives, anticoagulants, and bowel regimen drugs. An LPN was observed at the medication cart with the EMAR showing red flags for overdue 9:00 a.m. medications but stated the medications were not late and just not signed out. Another resident reported feeling sluggish and still being in bed because morning medications had not been given, while an empty 50 mL IV bag was observed at the bedside with no date, time, or nurse initials. The LPN later acknowledged that the IV bag should have been labeled and that medications should be signed out in the MAR, and the DON confirmed that 9:00 a.m. medications must be given between 8:00 a.m. and 10:00 a.m. and that IV bags must be labeled per facility policy.
Two residents with CHF had physician orders and care plan interventions for daily weights, but staff failed to obtain and document these weights on multiple days and did not consistently record reasons when weights were not taken. One resident experienced notable weight gain along with swelling, shortness of breath, and altered mental status before being sent to the hospital, with no documented provider notification of the weight variance. Another cognitively intact resident with leg swelling reported being weighed only weekly despite a daily weight order. Nursing staff, the NP, and the DON all acknowledged that daily weights, documentation of refusals or missed weights, and timely provider notification for significant weight changes were expected under facility policy, but these practices were not consistently carried out.
Two residents experienced care issues when one newly admitted resident did not receive multiple ordered medications, including psychotropic and respiratory drugs, from the afternoon of admission until the following morning despite available orders and an emergency medication supply, and another resident’s witnessed fall from bed to the floor, observed by several CNAs and reportedly assessed on the floor by an LPN, was not documented as a fall in the record and did not result in an updated fall care plan, even though the resident later self‑reported the fall and head pain to nursing staff.
A resident with a known lung lesion and multiple comorbidities developed abdominal pain and later severe left shoulder pain; imaging showed a lung mass invading the rib and multiple suspected metastases, including a lytic humeral mass with pathologic fracture. The physician ordered oncology, pulmonology, orthopedic, and interventional radiology (IR) referrals, but staff failed to ensure that oncology and pulmonology referrals were successfully transmitted and acted upon, did not provide required CT images to IR for a lung biopsy order, and allowed an orthopedic appointment for the pathologic humeral fracture to be missed due to short staffing without rescheduling or informing the POA. The ADON acknowledged forgetting to follow up on the pulmonology referral and IR requirements, and the facility had no policy on following physician orders. During this time, the resident experienced ongoing pain, falls, and functional decline while expressing a desire for cancer treatment, and neither the resident nor POA refused treatment after the new CT findings, leading surveyors to cite a failure to provide timely follow‑up and treatment of known suspicious masses that had metastasized.
A resident with diabetes, neuropathy, chronic foot ulcers, MRSA bacteremia, and a history of toe amputation experienced progressive worsening of a left plantar foot wound with exposed bone while in the facility’s care. Wound notes showed the lesion enlarging over time, and hospital and podiatry orders directed IV Daptomycin every 24 hours, twice‑daily saline wet‑to‑dry dressings, PICC assessments, lab monitoring, and pre‑surgical Hibiclens. MAR review revealed that ordered wound treatments were not documented for an extended period, multiple IV antibiotic doses were missed or given at inconsistent times, PICC checks and lab result faxing were omitted on several days, and a Hibiclens dose was not given. The podiatrist and clinic staff reported making numerous calls and sending orders to arrange urgent surgery due to exposed bone and osteomyelitis, but facility leadership did not return calls for about a week, and staff confirmed the podiatrist’s repeated, frustrated attempts to reach the DON. During this time, the facility had no wound care policy and had been without a wound nurse for about a month, with an LPN informally covering wound duties while also working the floor. Surgery was eventually performed, and more of the resident’s foot was amputated due to infection, which the podiatrist attributed to the delay in scheduling and incomplete coordination of ordered care.
A nurse left her assigned unit for several hours during an overnight shift, resulting in multiple residents’ needs going unmet, including a resident with complex cardiac and psychiatric conditions who could not obtain requested anxiety medication, and another resident with COPD and CHF who experienced anxiety and breathing problems without timely nursing intervention. A CNA reported that a needed wound dressing change was not performed despite repeated calls, and paramedics later responded to a male resident’s 911 call stating he was on the floor and could not find the nurse. Staff and residents described prior issues with the same LPN, including wrong medication administration and refusal to provide ordered pain medication, and stated that this LPN was not to pass medications to certain residents. Documentation and grievance records did not reflect these concerns, and there were discrepancies between staff notes and police dispatch times about when the LPN was actually on break and contacted by law enforcement.
A resident with multiple comorbidities and dependence on a mechanical lift for transfers sustained a scalp abrasion when the lift struck her head during a transfer. Several staff, including an RN, LPNs, the wound nurse, and the DON, viewed the injury but did not complete or document a thorough wound assessment with measurements or detailed description in the EMR, and no treatment was initiated. The incident report noted a scraped scalp, neuro checks, and severe pain, but lacked a full wound assessment, and subsequent skin documentation only briefly mentioned a closed abrasion without size or appearance details, while the resident reported that the wound was not measured or treated and still had a scab weeks later.
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