Marshall Nursing And Rehabilitation Community

concerns, but noted not that morning.

The progress note revealed R2 was sent out to the hospital.The progress notes revealed R2 did not return to the facility until 7/1/2025. In an interview on 8/19/2025 at 12:33 PM, Licensed Practical Nurse (LPN) D stated that she and two CNAs had attempted to obtain urine from R2 three times for the UA on 6/5/2025 but was not successful. LPN D said she did not call the Physician and report to R2's Physician that the UA was not able to be obtained.In an interview on 8/20/2025 at 8:40 AM, LPN D said she did not recall signing her initials to R2's TAR stating that she obtained the UA. LPN D said she must have put her initials on the TAR, because upon review of R2's TAR, LPN D confirmed it was her initials.

However, LPN D stated R2's UA was not performed and said she did not notify the Physician of that. LPN D said there was no process that was followed with transcribing Physician's orders and said Physician orders were not being transcribed correctly.In an interview on 8/20/2025 at 8:58 AM, CNA E stated that R2 had been more confused and would just stare and not react to her. CNA E said that on 6/25/2025, R2 was more confused and sleepier. CNA E said R2 had been more confused and sleepier about 3 days before she was sent out to the hospital on 6/25/2025.In an interview on 8/20/2025 at 10:34 AM, RN C stated that she could recall the order for R2's UA which was in June but could not recall an order for one in May. RN C said the UA was never obtained. RN C further explained the expectation was that the nurse calls the Physician to make the Physician aware that the UA could not be obtained and see what the Physician wanted to do about it. RN C, upon review of R2's EMR, stated that she did not see that anyone called R2's Physician about not being able to obtain the UA. RN C also stated that she did not see any UA results for the UA ordered on 5/20/2025.RN C stated that the process for transcribing Physician's order was when a Physician gave a verbal order or wrote an order in the resident's EMR then the nurse was to transcribe the order and assure the order went onto the resident's MAR or TAR if applicable. RN C stated that the practice/process at the facility for transcribing orders was not very good.Review of a hospital history and physical (H&P) report dated 6/25/2025, revealed R2 presented to the emergency room (ER) with a reported altered mental status.

The H&P revealed R2 had a family member with her in the ER who told the Physician that R2 had an altered mental status due to a UTI, and that she had been trying to get the staff at the facility to obtain a urinalysis for the past two weeks.Continued review of the hospital H&P revealed that R2 had a UA test performed while in the ER which showed the results of a positive UTI and ultimately resulted in R2 having to have IV (intravenous) antibiotics and be admitted to the hospital where she stayed for six days.

Facility ID: