A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
A resident with type 2 DM did not receive two scheduled weekly Mounjaro injections as ordered, with no documentation in the EMAR or progress notes explaining the omissions, no entry on the incident log, and no notification to the PCP, despite facility policies requiring documentation and rationale for missed medications. In a separate incident, an LPN administering ordered long-acting and short-acting insulin via insulin pens to another resident with type 2 DM failed to prime the pens and did not hold them in place at the injection site for the required time, contrary to the facility’s clinical checklist and expectations confirmed by the DON.
Surveyors found that the facility did not follow physician orders or its own policies for timely medication procurement and administration for four residents. One resident returned from the hospital on comfort measures with new PRN orders for atropine, lorazepam, and morphine for secretions, anxiety, pain, and air hunger, but the comfort kit medications were not available, clarification was not obtained, and morphine was not administered until the next day. Other residents admitted with multiple chronic conditions, including AFib, VTE history, COPD, diabetes, hypothyroidism, heart failure, and psychiatric disorders, had numerous scheduled medications either started late or given inconsistently, as documented on the MARs and in progress notes stating medications were not available or still pending from the pharmacy. Residents interviewed reported no negative impact, but the DON and Administrator acknowledged they knew medications for new and readmitted residents were not being delivered consistently or timely and that they had not notified the physician when medications were unavailable or not dispensed as ordered.
Surveyors found that the facility failed to enter and implement PRN oxygen orders for two residents with significant respiratory conditions. One resident with a history of pulmonary embolism and another with COPD each had admission orders from their PCPs for oxygen PRN to maintain O2 sats at 90%, but these orders were not entered into their Order Summaries. For the resident with COPD, documentation showed O2 saturation dropping to 82% with no record that supplemental oxygen was provided. The facility’s medication administration policy requires documentation in accordance with physician orders, and the DON acknowledged that standing orders are expected for all residents but that charts are not consistently reviewed, resulting in the missing PRN oxygen orders in the EMAR.
A resident with diabetes and multiple chronic conditions had a standing sliding scale Humulin insulin order requiring specific doses for blood glucose levels over 400. Facility policy required medications to be administered per PCP orders. On several occasions, the resident’s blood glucose readings were significantly elevated, yet the medical record contained no evidence that insulin was administered or what dose, if any, was given. The DON and an RN consultant confirmed there was no documentation that the ordered sliding scale insulin was provided at those times.
A resident with a diagnosis of constipation, who was cognitively intact and dependent on staff for toileting, went multiple days without a BM. Although PRN orders were in place for Dulcolax, Milk of Magnesia, prune juice, and senna, the MAR showed none were given, and there was no documentation of assessment or PRN treatment for constipation. The DON confirmed the ordered PRN constipation meds were not offered or provided as ordered.
A resident admitted with multiple fractures and post-surgical pain had a Buprenorphine transdermal patch ordered weekly, with instructions to remove the old patch and rotate sites. Medication records showed the patch was applied on two consecutive weeks, and an incident report later revealed MAs failed to remove the old patch on two subsequent application dates, leaving multiple patches in place. Although the facility’s policy required narcotic patches to be checked three times daily and the DON expected staff to remove the old patch before applying a new one, there was no system in place at the time to ensure this occurred.
A resident with a PICC line and orders for daily weights did not receive care consistent with facility policy and practitioner directives. The facility’s infusion therapy policy required arm circumference and weekly external catheter length measurements for PICC lines, but the resident’s orders lacked PICC cap change and external length measurement directives, which the WIN acknowledged should have been present. Additionally, despite an order to obtain daily weights and notify the provider of weekly gains over 3–5 lbs, staff recorded a large weight increase within one day and did not report it to the provider, as confirmed by the ADON.
Two residents with vascular disease and surgical/venous wounds did not receive wound care as ordered. For one resident with a venous ankle ulcer, an LPN performed dressing care without the ordered ABD pad and instead used the technique ordered for the toes. For another resident with diabetes, peripheral vascular disease, and a left 3rd toe amputation, wound vac orders for dressing changes every 3 days and constant suction, as well as backup wet-to-dry and other wound treatments to the left foot and leg, were frequently not completed or not documented as completed. Progress notes described periods when the wound vac was not running due to a dead battery and missing charger, with no documentation of how long it was off or what interim care was provided. A provider later documented a macerated amputation site with slough and new skin breakdown, and the resident reported that wound vac dressings were changed only weekly and that there were multiple six-day stretches without dressing changes. Staff interviews revealed lack of formal wound vac competency training and absence of a wound vac policy, and the DON acknowledged that wound care orders were not followed.
Failure to follow bowel protocol for a resident with chronic idiopathic constipation. The resident had standing orders for daily stool softener and PRN polyethylene glycol, but records showed multiple days without a BM, no evidence the PRN laxative was given, and no documented bowel assessment or interventions by nursing staff. The ADON confirmed the resident was not assessed or treated for constipation during the month reviewed.
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