A resident with a diagnosis of constipation and moderately impaired cognition had PRN orders for docusate sodium and Glycolax but went multiple five-day periods without a documented BM, and staff did not administer the ordered PRN bowel medications. Documentation showed the resident was always bowel incontinent and used disposable briefs, and a triggered CAA lacked analysis. A CNA confirmed the resident experienced constipation and that BMs were recorded in the EMR, while a nurse verified the absence of BMs on the noted days and the lack of PRN medication use. An administrative nurse stated nurses were expected to give PRN bowel meds after three or more days without a BM, and no bowel management policy was provided.
A resident had a PRN order for diphenhydramine 50 mg by mouth three times daily without any documented diagnosis or indication, despite having documented insomnia and anxiety, intact cognition, no skin issues, and independence with ADLs. The medication was not reflected in the care plan or in any progress, provider, dermatology, pharmacy, or psych notes. A consultant pharmacist later confirmed the absence of an indication and acknowledged missing it during a prior review, while a CMA, an LN, and an administrative nurse all stated that PRN and other medications are required to have a diagnosis or reason for use. The facility did not provide a policy governing PRN medication orders.
A resident with DM, morbid obesity, and prior stroke, receiving daily insulin and oral diabetes meds, had multiple blood glucose readings significantly above ordered parameters over several months. The care plan and physician orders required staff to notify the provider for values above a specified threshold, but progress notes contained no documentation of such notifications. A CMA reported using informal notification thresholds that did not match the provider’s orders, and an administrative nurse described notification practices based on symptoms and faxing, with expected documentation of provider contact. The facility’s written notification parameters assigned licensed nursing staff responsibility for contacting the PCP when clinical problems arose, but this was not carried out or documented for this resident’s repeated hyperglycemic readings.
A resident with diabetes, impaired cognition, and a complex hypoglycemic regimen (including insulin and oral agents) had physician orders for periodic CBC, CMP, and HbA1c to monitor her condition and medication effectiveness. While some labs were completed earlier, the EMR showed that a later scheduled CBC and HbA1c were not done, and there was no documentation explaining the omission or any rescheduling. An administrative nurse confirmed the labs were missed, despite facility policy requiring monthly pharmacist drug regimen review using lab values and ensuring pharmacist access to lab results, resulting in a failure to adequately monitor the effectiveness of the resident’s hypoglycemic medications.
A resident with HTN and CHF, moderate cognitive impairment, and dependence for ADLs had physician orders for daily isosorbide mononitrate and amlodipine with specific BP and pulse hold parameters. Over several months, MAR reviews showed both antihypertensives were repeatedly administered when BP and/or pulse readings were outside the ordered ranges, despite the care plan directing staff to follow medication orders and obtain and act on vital signs, and despite staff and consultant statements that medications should be held when parameters were not met. The facility’s policy required adherence to physician orders and notification of the DON and physician if orders could not be followed, but the documented medication administration did not align with these requirements.
A resident with hypothyroidism was prescribed levothyroxine 50 mcg by mouth every other day, but the facility did not obtain thyroid-stimulating hormone (TSH) labs to monitor the effectiveness of this therapy over an extended period. The care plan and facility policy called for medication regimen review and monitoring of labs and diagnostic tests as ordered, and an administrative nurse reported expecting labs for residents on levothyroxine. However, review of the EMR showed no TSH orders or completed TSH labs, resulting in a failure to ensure the resident’s drug regimen was free from unnecessary drugs.
A resident with diabetes who was dependent on staff for care and received daily insulin had blood sugars checked four times per day without any physician-ordered blood glucose parameters documented in the EMR or care plan. Nursing staff reported relying on personal judgment to determine when to notify the physician, and a CMA stated she did not know what the parameters should be, noting that they were present in a prior computer system but not in the current one. An administrative nurse acknowledged that physician-ordered parameters and clear care plan directions for diabetes management were lacking, and the facility could not provide a blood sugar management policy when requested.
A resident with multiple complex conditions did not have blood pressure or pulse monitored prior to receiving a beta blocker, and physician orders for topical Voltaren gel lacked clear dosage instructions for some applications. Staff interviews confirmed uncertainty about monitoring requirements and acknowledged that medication orders should specify dosages, as required by facility policy.
A resident receiving Reglan for nausea, with a history of CHF, diabetes, and GERD, was not monitored for adverse effects using the AIMS test or any alternative method. Staff indicated that the facility's system did not trigger AIMS testing for this medication, and no policy for monitoring medication side effects was available upon request.
A resident with chronic pain and multiple sclerosis was prescribed Voltaren gel for pain management, but the physician's order lacked a specified dosage. Staff and administrative interviews confirmed that all medications should include a dose, and facility policy requires adequate indications for use. This omission resulted in a deficiency related to unnecessary drugs.
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