Staff failed to demonstrate competency with insulin pen administration and respiratory equipment cleaning. Three LPNs gave insulin to three residents without priming the insulin pen needle, despite orders for insulin in residents with DM. Staff also cleaned a resident’s non-invasive ventilation mask using wipes, alcohol, and paper towels instead of the facility’s soap-and-water method, and the tubing was not cleaned; one LPN stated she had never received training on cleaning the mask and tubing.
Two residents received Voltaren 1% gel without the dosage ordered by the physician, including one resident with severe cognitive impairment and another with moderate cognitive impairment. In addition, staff did not document notifying the physician of a resident’s edema and incoherent status, did not complete a post-nebulizer assessment, and did not follow the care plan for daily weights and monitoring of breath sounds.
Failure to Administer PRN BP Medication as Ordered: Nursing staff failed to give a resident’s PRN Clonidine HCL for hypertension on multiple occasions when the resident’s diastolic BP was above the ordered parameter. The resident had CHF, AFib, angina, HTN, and moderate cognitive impairment, and both an LPN and the DON confirmed the missed administrations.
An agency RN providing wound care to a resident with a stage 4 sacral pressure ulcer, diabetes, and UTI failed to follow infection control practices and had no documented competency validation. During an observed treatment, the RN and a CNA did not wear gowns despite Enhanced Barrier Precautions signage, and the RN repeatedly changed gloves without performing hand hygiene, placed used gloves on surfaces instead of discarding them, and continued wound care and incontinence care without sanitizing or washing hands. The RN later acknowledged not using hand sanitizer or soap and water between glove changes, not changing gloves after cleansing the wound before applying gentian violet, and placing soiled gloves on the bed. She reported having performed wound care for all residents for two weeks without training on facility policies or procedures and without shadowing another treatment nurse, and the administrator confirmed there was no documentation of training or competency assessment for this agency RN.
Nursing staff failed to follow medication administration and documentation requirements for two residents. For one resident with intact cognition and multiple medical conditions, an LPN left a cup containing four oral medications unattended at the bedside and did not remain with the resident to ensure the medications were taken, contrary to facility policy. For another resident with rhabdomyolysis, acute pulmonary edema, CKD, heart failure, and atrial flutter, physician orders for IV Lasix twice daily over several days were not documented as administered on multiple ordered times, and the DON and corporate nurse confirmed the absence of documentation. These issues reflect a lack of required competencies and adherence to medication administration procedures by licensed nursing staff.
Nine staff members, including CNAs and a CNA Supervisor, did not follow proper mechanical lift procedures as outlined by facility policy and the manufacturer's guidelines. Staff were observed and reported locking the caster brakes during resident transfers, instead of leaving them unlocked as required, demonstrating a lack of competency in safe lift operation.
Nursing staff did not properly assess or document care for two residents, including failing to record the rationale for a foot x-ray for one resident and not completing an assessment when another resident reported abdominal pain before hospital transfer. Leadership confirmed the lack of required documentation and assessment by nursing staff.
Nursing staff failed to review all discharge documentation and clarify medication orders with the physician, resulting in a resident not receiving prescribed medications, including a necessary home medication, during their stay. The admission orders were based on incomplete information, leading to discrepancies in medication administration.
Nursing staff were allowed to perform wound care treatments without verified training or competency evaluation, resulting in improper documentation and inadequate wound coverage for two residents. The facility relied on self-reported experience rather than direct observation or skills assessment, and wound dressings were not consistently dated, initialed, or applied according to policy.
Nurses did not start a physician-ordered medication, Naltrexone, for a resident with severe dementia and hypersexual behavior, despite clear recommendations in the psychiatric evaluation and documentation in the medical record. The DON confirmed the medication was never initiated as ordered.
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