Failure to Administer Ordered Prednisone: A resident with COPD, cough, congestion, and other respiratory diagnoses was ordered Prednisone for 4 days, but the MAR and nursing notes showed doses were not given because staff were waiting on pharmacy. The resident was observed coughing up phlegm and stated she had been supposed to start a steroid but had not. An LPN confirmed the medication was not delivered and was not administered as ordered, and the NP confirmed the order was expected to be carried out.
A resident's narcotic record was not maintained and reconciled when an LPN administered Pregabalin 25 mg but failed to sign it out on the resident's Individual Narcotic Record. During observation, the documented count was 47 while the actual count on the narcotic card was 46, and the LPN confirmed the medication should have been signed out at the time of administration.
Surveyors found that the facility failed to ensure an ordered antihypertensive medication was available and administered as prescribed. A resident with essential HTN had a standing order for Hydralazine 10 mg PO BID, but during a medication pass an LPN did not have the drug on the cart or in storage, and confirmed it was not in the facility. Record review showed the last dose was given the prior evening and that the next scheduled morning dose was not documented as administered. The LPN acknowledged the medication had not been reordered in advance as required by facility policy, and the administrator confirmed that medications ordered by physicians are expected to be available at all times and refilled before running out.
A resident with chronic pain and opioid dependence was left without prescribed Hydrocodone-Acetaminophen due to failures in medication ordering and communication among nursing staff. In response, an LPN administered Tylenol without a physician order and later borrowed pain medication from another resident, violating medication protocols. The resident's family raised concerns about pain management, and the resident was transferred to the hospital for pain control.
A resident with chronic pain did not receive scheduled Morphine due to failures in medication refill and communication processes. Nursing staff did not follow up with the pharmacy or escalate the issue when the medication ran out, resulting in the resident missing three consecutive doses, experiencing severe pain, and requiring transfer to the ER after alternative pain medications proved ineffective.
A resident with a history of chronic pain and a previous fall was unable to receive prescribed Hydrocodone-Acetaminophen for pain relief because the medication was not reordered in time and was unavailable when requested. Staff confirmed the medication was out of stock and not administered as ordered.
A resident with COPD and multiple care needs was found with an Albuterol inhaler left unattended at bedside without a required assessment or physician's order for self-administration. Facility policy mandates assessment, interdisciplinary review, and proper documentation for self-administration, none of which were completed. Staff confirmed the medication should have been secured and that administration was not properly documented on the MAR.
Nursing staff did not administer medications within the required timeframe for two residents, resulting in multiple scheduled medications being given late. Facility policy requires medications to be given within one hour of the prescribed time, and staff confirmed that these delays were not in accordance with physician orders.
Nursing staff failed to follow required procedures for wasting and documenting controlled substances. In one case, a nurse wasted a Tramadol tablet without a witness signature, and in another, a Hydrocodone/APAP tablet was improperly returned to its blister pack after being opened. The DON confirmed that staff are aware of the correct protocols, but these were not followed.
A resident with insomnia did not consistently receive prescribed Doxepin HCl at the scheduled time, with multiple documented instances of late administration well beyond the facility's one-hour policy window. The DON confirmed these delays, which were not in accordance with physician orders.
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