Medication administration was not performed according to orders and facility procedures for three residents. An RN gave morphine to one resident outside the ordered respiratory-rate and pain parameters, an LPN administered multiple G-tube meds by pushing them with the syringe plunger instead of gravity delivery, and an RN gave a Breyna inhaler without offering mouth rinsing afterward.
The facility failed to follow professional standards for medication administration and weight monitoring. An LPN discontinued Eliquis for a resident without a new order, and another resident missed Pyridostigmine doses without documented hold parameters or provider notification. The facility also did not re-weigh residents after a large weight gain and a large weight loss, including a resident with severe protein-calorie malnutrition.
The facility failed to meet professional standards of quality by not documenting required post-fall assessments for two residents. In one case, a resident was found on the floor with head and leg pain, a lump on the head, and later increased right leg pain after being moved to bed; although an RN reported performing an assessment, there was no documentation of that assessment, no recorded VS, and no neuro checks despite the resident remaining in the facility for hours before ER transfer. In the second case, a resident was found on the floor after attempting an independent transfer, noted as having no skin issues and moved to a w/c, with an IDT note later referencing a full body assessment by the unit manager; however, no detailed assessment, VS, or injury documentation was found in the record. These omissions conflicted with facility policies requiring documentation of the resident’s condition, assessment data, VS, and interventions after a fall.
The facility did not notify the provider of significant weight changes or missed daily weights for two residents with CHF, despite physician orders requiring notification for specific weight gains. Documentation and staff interviews confirmed that the provider was not informed as required.
A resident with multiple wounds did not consistently receive wound care as ordered by the physician, with several missed treatments and no documentation of care completion or refusals. The DON confirmed that the medical record and TAR lacked required documentation for both completed and refused wound care.
A resident with diabetes did not receive short-acting and long-acting insulin at the times specified by physician orders and manufacturer instructions. Insulin doses were frequently administered too early or too late in relation to scheduled mealtimes, and staff did not notify the DON or physician about these deviations. The resident reported receiving insulin after eating on multiple occasions, and documentation confirmed repeated failures to follow proper medication administration timing.
A resident with bipolar disorder and Tardive Dyskinesia received multiple medications, including Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion, significantly later than scheduled on numerous occasions. The resident, who was cognitively intact, reported frequent late medication administration, which was confirmed by audit reports and staff interview. This practice did not comply with facility policy requiring medications to be given within 60 minutes of the scheduled time.
A medication cart was found with an unlabeled cup containing multiple pills, including a controlled substance, that had been pre-poured by a night shift LPN and left for a day shift RN to administer to a resident. The medications were not prepared and administered by the same nurse, and the controlled substance was not double locked, violating both professional standards and facility policy.
A resident was administered PRN Morphine Sulfate multiple times despite documentation of a pain level of 0, contrary to physician orders specifying administration only for pain rated at 5/10 or higher. The Unit Manager confirmed the medication was given without clinical indication, representing a failure to follow professional standards for medication administration.
A resident scheduled for a gradual dose reduction of Lyrica did not receive the correct reduced dose as ordered by the physician. Instead, the resident continued to receive the previous higher dose at noon for several days because the correct dosage was not available in-house, and staff did not follow the updated order. This resulted in a failure to meet professional standards for medication administration.
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