A resident with orthostatic hypotension and other comorbidities had a physician order for Midodrine with instructions to hold the medication if systolic blood pressure (SBP) exceeded 120. Review of the MAR showed multiple instances where Midodrine was documented as administered despite SBP readings above the ordered parameter, and in one case the MAR conflicted with a progress note that stated the dose was held. Interviews with LPNs and the DON confirmed that staff are expected to check BP before giving Midodrine, follow hold parameters, and document when medications are held, yet the DON acknowledged that Midodrine was given outside the ordered BP parameters and that documentation was incomplete or inconsistent with facility policy requiring accurate preparation, administration, and documentation of oral medications.
The facility failed to ensure PRN pain medications were administered within physician-ordered pain scale parameters for three cognitively intact residents with multiple comorbidities, including diabetes, dementia, joint replacement aftercare, encephalopathy, respiratory failure, and acute kidney failure. MAR reviews showed acetaminophen, tramadol, and oxycodone were repeatedly given for pain ratings outside the ordered ranges over several months. During interviews, an LPN, the ADON, and the interim DON each confirmed that medications had been administered outside the prescribed parameters and described associated risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. The facility’s Medication Administration policy lacked specific language on following physician-ordered pain parameters, despite requiring review of the MAR and three checks against the physician’s order, pharmacy label, and MAR.
A resident with multiple medical conditions, but no diagnoses or orders supporting Duloxetine or Omeprazole, was given these two medications in error when an RN took over a partially completed med pass from an agency nurse who had been sent home. The RN, relying on incomplete handoff information, accessed the wrong EMAR, did not properly verify the resident’s identity against the MAR, and did not observe the resident during medication ingestion. Only after administration did the RN realize the EMAR mix-up, by which time the resident had already taken the unordered Duloxetine 30 mg and Omeprazole 20 mg, contrary to facility policy requiring adherence to the 10 rights of medication administration and proper resident identification.
A resident with orthostatic hypotension and hypertension received blood pressure medication outside of physician-ordered parameters, as the MAR showed doses were administered when systolic blood pressure was above the specified threshold. Documentation was inconsistent, with some instances lacking explanatory notes and others marked as administered despite being held, as confirmed by LPN and DON interviews.
A resident with muscle weakness and neurological impairment did not receive a physician-ordered speech evaluation due to an order entry error that marked the order as completed before services were provided. The speech therapist was not notified of the order, and the resident confirmed never receiving speech therapy.
A resident with diabetes was administered Metformin mixed with pudding prior to breakfast, rather than with a meal as ordered by the physician. Multiple LPNs and the DON confirmed that a spoonful of pudding does not constitute a meal, and facility policy and drug references specify that Metformin should be given with meals. The medication was given before the scheduled breakfast, contrary to the physician's order.
Multiple residents did not receive medications in accordance with physician orders and professional standards. One resident with depression and dementia had a lidocaine 4% patch still on the leg despite the MAR indicating it had been removed the prior evening, and was given 50 mg of sertraline when the active order and MAR required 100 mg. Another resident with chronic pain had a lidocaine patch applied to the ankle each morning without any ordered or documented removal schedule, and an LPN was observed removing an existing patch and immediately applying a new one. A third resident with hypertension and UTI had a lidocaine patch ordered for the shoulder in the morning, but no removal time was ordered or transcribed, and an RN was observed removing an old patch and applying a new one without a defined wear interval. A fourth resident on furosemide for edema had an order for 20 mg BID without specified times, yet the MAR scheduled and staff administered doses at approximately 8:00 and 12:00, only about 3.5–4 hours apart, even though neither the provider nor the pharmacist had ordered or recommended that timing and facility policy required adherence to written orders and established medication schedules.
A resident with COPD did not receive prescribed doses of Tyvaso DPI as ordered, despite the medication being supplied by the family and available on site. Nursing staff were unaware of the medication's source and failed to administer it consistently, with multiple missed doses documented as 'on order' or unavailable. Facility policy required medications to be given per prescriber orders, but this was not followed, resulting in the deficiency.
A resident with end stage renal disease and moderate cognitive impairment did not receive consistent monitoring before and after hemodialysis, as required by physician orders. Documentation showed missing or incorrectly timed vital sign recordings, and staff interviews revealed confusion due to transportation issues and outdated orders in the system.
A resident with multiple infections did not receive several scheduled doses of IV antibiotics as ordered, and there was no documentation that the provider was notified about the missed doses. Nursing staff and the DON confirmed that provider notification was required but not completed or documented, contrary to facility policy.
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