A resident with diabetes and a history of lower extremity wounds had orders and care plans for weekly diabetic foot checks, weekly head‑to‑toe skin inspections, and daily foot monitoring, yet staff documented completed assessments with no issues while the resident’s legs and feet were not actually visualized, refusals were not consistently documented, and the provider was not notified despite the resident later being observed with dirty, adherent socks, a malodorous, raw‑appearing ankle area, and a blood‑tinged bandage stuck to the skin. Another resident with diabetes on hemodialysis had multiple scheduled and sliding‑scale insulin aspart doses administered significantly later than ordered, with no progress notes explaining the delays, while the resident and an RN reported that nighttime insulin was often late. A third resident admitted with anxiety and panic disorder had ordered lorazepam not available on the night of admission due to the prescription not being sent to the pharmacy, was unable to receive a dose from the backup supply because of a dose mismatch, and did not receive scheduled doses the following day, with no documented follow‑up by nursing on the cause or status of the delayed medication.
Failure to follow ordered skin treatment: A resident with a history of MS and prior cellulitis had a right lower leg venous ulcer that later resolved, but ordered dressing care continued. During an observed treatment, an RN rubbed the resident’s fragile right lower leg skin and called it light debridement before an LPN applied the ordered Xeroform, ABD pad, and Kerlix dressing. The DNS stated this rubbing was not part of the physician-ordered plan of care.
Two residents with cognitive impairment experienced frequent loose stools over an extended period, yet staff continued to administer constipation medications such as Miralax and senna and did not consistently use PRN loperamide as ordered. CNA documentation showed repeated loose stools and frequent incontinence care, and CNAs reported notifying medication aides and nurses, but the MAR reflected ongoing bowel care medications and minimal use of antidiarrheal treatment. Standing orders required holding bowel care with new onset diarrhea, and the DNS stated she expected staff to follow these orders and use appropriate PRN medications when residents had loose stools.
The facility failed to complete ordered skin assessments for a resident with malnutrition and a history of skin tears and did not follow physician orders for medication administration for two other residents. One resident’s documented skin tears were not followed by comprehensive skin assessments. Another insulin‑dependent resident received an extra insulin dose when an RN, relying on incomplete documentation, administered insulin a second time. A third resident with chronic pain and anxiety received higher‑than‑ordered evening doses of methadone and PRN clonazepam doses that exceeded the prescribed 24‑hour maximum, as confirmed by facility leadership.
A resident with depression and anxiety and a BIMS score indicating cognitive intactness had erythema under the neck fold that worsened in size and tenderness. An LPN documented notifying the provider, but there was no response in the provider notes, no follow-up documentation of additional calls, and no new treatment orders on the TAR.
A resident with diabetes, polyneuropathy, and a left great toe wound did not receive ongoing, comprehensive wound assessments as required by facility guidelines. Initial documentation from a wound clinic and a Skin and Wound Evaluation recorded wound size, tissue types, and drainage, but omitted key assessment elements such as wound edges, swelling, temperature, pain, treatment type, and care goals. After a later clinic note documented regression of the toe wound and aggressive debridement, no further Skin and Wound Evaluations were found in the record. A complaint was filed alleging the toe became infected due to negligence, and the resident reported continued pain. An LPN stated she performed wound care before discharge and noted only dried blood and blanchable redness, while the DNS acknowledged that, following the loss of a dedicated wound nurse, it was difficult for staff to complete the expected weekly wound assessments.
A resident with diabetes had a standing physician order and care plan for weekly diabetic nail care to be performed by licensed nurses, but staff interviews and observations showed that nail care, particularly to the left hand, had not been performed or maintained for an extended period. The resident’s left thumb nail was markedly thickened, elevated from the nail bed, and discolored, and another finger had minimal nail bed remaining. CNAs deferred nail care due to the resident’s diabetic status, RNs acknowledged not providing nail care to the left hand due to lack of skill and unclear documentation, and the DNS believed an outside insurer-managed service was responsible but could not produce documentation that such care occurred. This failure placed the resident at risk for unmet care needs and potential diabetes-related complications.
A resident with hemiplegia, previously evaluated as not appropriate to self-administer any medications, was found to have open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) stored in a bedside drawer. Record review showed there were no MD orders for several of these topical products and no order permitting self-administration. An RN case manager confirmed the absence of orders, and the resident reported self-administering the medications, demonstrating a failure to ensure medications were administered only as ordered and in accordance with the resident’s assessed ability.
A resident admitted with diabetes and a documented non-pressure chronic ulcer on the left foot had an ulcer and scabs on multiple toes and the top of the foot noted on admission assessments, and an MDS later confirmed a non-pressure chronic ulcer. However, no physician orders or wound treatments for the left foot ulcer were present in the clinical record for an extended period after admission, until nursing staff eventually messaged the physician and initiated treatment. An agency LPN could not recall confirming wound care orders at admission and stated that usual practice would be to contact the physician if orders were missing, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds.
A resident with hypothyroidism and other chronic conditions had a physician order for daily oral thyroid medication, but multiple doses were not administered over several days, as documented on the MAR and in nursing notes indicating the drug was on order, unavailable, and later on pharmacy back-order. Although staff contacted the pharmacy and noted an expected delivery, there was no documentation that the provider was notified of the missed doses or that an alternative source for the medication was pursued. In interviews, an LPN described a process for notifying leadership and the provider when medications are unavailable, and facility leadership stated they would have expected the provider to be informed of the unavailability and missed doses.
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