Nursing staff failed to meet professional standards when a CMA administered nighttime medications intended for a discharged resident to that resident’s former roommate without verifying identity or discharge status, as documented in the medical record and facility investigation. In a separate incident, an RN treated a resident’s hypoglycemic episode with Glucagon and documented that an on-call provider ordered a repeat glucose check and possible second dose, but no corresponding Glucagon order or follow-up fingerstick result was entered in the EHR. Additionally, staff reported performing ostomy appliance changes for a resident and stated this care was documented on the TAR, yet review of the TAR and EHR showed no documentation that ostomy care was provided despite an existing order for colostomy appliance care.
A resident with a MOLST indicating full code status was found unresponsive without a palpable pulse, and staff initiated CPR and used an AED, which advised no shock. Instead of immediately activating EMS as required by the facility’s CPR policy and AHA guidelines, the nursing supervisor first called the resident’s representative to confirm continuation of full code status and then contacted the on-call provider, who instructed that 911 be called. EMS was not contacted until after these calls, and upon arrival found the resident in cardiac arrest with cold skin and signs of rigor mortis before pronouncing the resident deceased. Facility leadership confirmed that staff failed to call 911 prior to contacting the resident’s representative and provider, contrary to professional standards of practice.
A resident receiving Methadone and PRN Oxycodone for pain did not have a follow-up pain assessment documented after a PRN Oxycodone dose, and the follow-up pain score was later entered in the EHR by an LPN who had not administered the medication and had worked the prior shift. Facility staff interviews confirmed that standard practice is to document pre- and post-administration pain scores and to contact the provider if PRN pain medication is ineffective. In a separate event involving the same resident, documentation and a CRISP report showed that while the resident was in distress, their oxygen saturation dropped to 86%–87%, but oxygen therapy was not initiated, and the DON stated that the nurse did not recognize the decreased oxygen saturation despite contacting the provider.
A resident with HTN had orders for Amlodipine and Metoprolol with parameters to hold doses if SBP was below 110 and, for Metoprolol, if HR was below 60. Despite this, Metoprolol was administered when the resident’s SBP was 101, and multiple BP readings below the ordered parameter were documented without evidence that the physician was notified or that medications were held as ordered. Separately, maintenance hot water logs showed the same temperature values carried across all resident rooms using lines and arrows instead of recording actual temperatures for each room, and the Maintenance Director acknowledged the logs were not completed accurately.
Medication administration was not provided according to physician orders for two residents. One resident with opioid dependence received Oxycodone outside the ordered pain parameters on multiple occasions, and another resident ran out of Pregablin because a refill was not requested before the medication supply was exhausted; the MAR also showed delayed Pregablin doses without documentation that the physician was contacted for guidance.
A resident with Influenza A and bacteremia did not receive ordered Tamiflu or the adjusted dose of IV Vancomycin as prescribed, and there was no documentation that the pharmacy or prescribers were notified when these medications were not available or not administered. In addition, an IV NaCl order initially lacked a specified volume, and a subsequent IV fluid order that required documentation of total volume infused each shift was not properly documented on the MAR. Interviews with an LPN, the DON, a physician, and an NP confirmed lack of awareness of missed doses and incomplete documentation, as well as failure to clarify incomplete IV fluid orders.
An RN prepared Vitamin B-1 100 mg for a resident from a bottle labeled with another resident's name, stating it was house stock and matched the ordered medication, route, and dose. The ADON/IP later confirmed that medications labeled for a specific resident cannot be used as house stock for others because they were dispensed for that resident.
A resident with ongoing diarrhea reported that the facility was not doing anything about it. A stool test for C. diff was ordered, but the record showed it was signed off as completed even though no lab result was found and the specimen was not picked up; the binder noted “no stool.” An LPN said the resident had no BM during her shift and the need for the specimen was passed to the next shift, while the ADON confirmed the order should not have been marked complete without a specimen and should have been extended when stool was not obtained.
A resident received a double dose of oxybutynin ER over an extended period due to a medication order error that was not reported or corrected when first identified. A nephrology NP consultant documented that the resident was on a duplicate oxybutynin dose and recommended monitoring for LUTS while not recommending continuation of that drug, but did not notify facility staff or follow up, instead only uploading the consult into the EHR days later. The DON later learned that the NP had chosen not to report the error because she did not want to get anyone in trouble, resulting in the medication error remaining unaddressed.
An LPN administered a PRN oxycodone dose to a resident for pain but failed to document the administration on the MAR, even though the narcotic control book showed the medication was signed out. In separate med pass observations, the same LPN gave multiple 9:00 AM scheduled medications, including metformin, Eliquis, antihypertensives, diuretics, GI meds, supplements, and inhaled therapy, to two residents more than an hour late, with the eMAR highlighting the overdue status. The LPN acknowledged the late administration and cited responsibility for two hallways of residents.
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