Two residents requiring modified diets and direct or 1:1 supervision during meals were observed eating without the required staff supervision and with access to straws, despite physician orders and care plans specifying otherwise. Staff confirmed these orders were not followed during the observed mealtimes.
Staff did not adhere to facility policy for insulin pen preparation and administration for three residents. Insulin pens were primed with the needle cap on, held horizontally, and in some cases, with an incorrect number of units, rather than following the required procedure of removing the cap, holding the pen upright, and dialing the correct dose.
Staff did not administer medications within the required timeframe for multiple residents, with medications given more than one hour late on several occasions. The facility lacked a policy on timely medication administration, and an administrative nurse confirmed the expectation for medications to be given within one hour of the scheduled time.
A resident was given a higher dose of Vitamin D than ordered because the facility's stock only included Calcium with Vitamin D 400 units, while the physician had ordered Calcium with Vitamin D 200 units. The nurse did not clarify the order with the provider, resulting in administration of an inaccurate medication dose.
A medication aide prepared medications for a resident and later handed them to a nurse, who then administered them, contrary to facility policy and professional standards requiring staff to administer only medications they have personally prepared. The resident's medication administration record reflected the aide as the person who administered the medications, despite the nurse actually giving them.
Staff did not follow professional standards for insulin administration and failed to notify a physician when a resident's blood glucose readings were repeatedly above the ordered threshold. Additionally, a nurse was observed priming an insulin pen incorrectly, not in accordance with manufacturer instructions.
Facility staff did not transcribe a physician's order for multiple blood tests into the electronic medical record and did not ensure the collection of the required blood specimens for a resident. Administrative staff confirmed the omission, and there was no documentation that the laboratory tests were completed.
Staff did not adhere to professional standards during insulin administration, including improper priming of insulin pens and failure to notify a physician about out-of-range blood glucose levels for a resident with diabetes. These actions were not in accordance with facility policy and were confirmed by administrative staff.
Nursing staff did not clarify or accurately transcribe a new medication order for a resident, resulting in a discrepancy between the medication card and the MAR for Metoprolol. Additionally, a nurse failed to correctly prime an insulin pen for another resident, not following manufacturer instructions. Administrative staff confirmed that medication orders should be clarified when discrepancies are found.
Staff failed to prime an insulin pen before administration for a resident, contrary to facility policy, and did not transcribe provider orders for continuous glucose monitoring for another resident. Additionally, lorazepam was administered to a resident without an active physician order after the previous order had expired.
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