Failure to Document Non-Pharmacological Pain Interventions Before PRN Opioids: Two residents received repeated PRN oxycodone-acetaminophen doses for pain, but the MAR and EMR contained no documentation of pain location or any non-pharmacological interventions attempted and failed before administration. Both residents had care plans calling for non-pharmacological pain relief measures, and the DON stated that such interventions should be attempted and documented before PRN opioids are given.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
A resident with end stage kidney disease, stroke, and diabetes received Plavix, Furosemide, and Lokelma together on dialysis days, contrary to manufacturer guidance that Plavix and other oral medications should be separated from Lokelma by at least two hours. An LPN administered these medications together multiple times weekly, and the consultant pharmacist's monthly reviews did not identify the issue, resulting in a failure to ensure accurate medication regimen review and administration.
Three residents received antibiotics for UTIs without meeting clinical criteria or having positive culture results. Antibiotics were started based on minimal or non-specific symptoms, such as a single low-grade fever or altered mental status, and in one case, continued even after a negative C&S result. Staff could not provide justification for the antibiotic use or explain the rationale for therapy in the absence of confirmed infection.
A resident with a history of pain and psychiatric diagnoses received frequent PRN opioid medications without consistent documentation of pain assessments or attempts at non-pharmacological interventions prior to administration. The DON confirmed that facility practice required such documentation, but records showed this was not followed, and the facility's policy lacked guidance on opioid administration.
A resident with vascular dementia and severe cognitive impairment was prescribed Seroquel without any documented attempt at a Gradual Dose Reduction (GDR), as required by facility policy for psychotropic drugs. The NHA could not provide evidence of a GDR attempt during the survey.
The facility failed to obtain a signed consent for treatment with an antipsychotic medication for a resident and did not prevent the administration of duplicate diltiazem medications to another resident, resulting in a medication error as confirmed by the DON.
A resident with multiple diagnoses received both vitamin D2 and D3 concurrently after a physician accepted a pharmacy recommendation to switch formulations, but the original vitamin D2 order was not discontinued. This resulted in duplicate weekly administration and excessive dosing, which was not identified due to a missed step in the medication order review process.
A resident prescribed Depakote for mood stabilization did not receive the recommended routine laboratory monitoring for valproic acid and ammonia levels, despite a physician's order and pharmacist's recommendation. Review of records and confirmation from the DON showed that these labs were not obtained over the past year.
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