Two residents had PRN acetaminophen given without consistent documentation of NPI attempts before administration. One resident with dementia and a right arm fracture had acetaminophen given multiple times, but the interventions were marked not applicable. Another resident with HTN, anxiety, and osteoporosis received acetaminophen for pain, but not applicable was documented instead of an NPI code, and no NPIs were recorded.
Digoxin Given Despite Low HR: A resident with chronic atrial fibrillation received Digoxin even when the HR was below 60 bpm on multiple occasions. The EMAR showed the medication was administered despite low HR readings, and the DON and an RN confirmed the drug should have been held and the provider notified.
A resident with anxiety and depression, documented as alert and oriented, had a physician order for Haldol 2 mg daily that was to be held pending clarification. Despite this hold instruction and without obtaining consent, staff administered Haldol as recorded on the EMAR. The resident’s family contact reported the resident was not supposed to receive Haldol due to concerns about hand tremors, and the Administrator/RN confirmed that the psychotropic medication had been given without the required consent.
A resident with moderate cognitive impairment had a lidocaine patch order that was transcribed and carried out as 24-hour continuous use instead of the intended 12 hours on and 12 hours off. The patch was applied daily for 13 administrations, and the resident and multiple nurses stated this was not the correct wear schedule; the DON acknowledged the provider intended only 12 hours of use.
A resident’s metoprolol was administered despite a physician order to hold the medication when systolic BP was below 110. Review of the MAR showed multiple doses were given when the resident’s systolic BP was under the ordered parameter, and an LPN acknowledged the medication should have been held; the DON stated staff were expected to follow the BP parameters and notify the provider.
A resident with atrial fibrillation was receiving Eliquis daily and was later started on Naproxen 250 mg BID for pain, ordered by the MD as a two-week short course. The RCM entered the Naproxen order into the MAR without an end date, and the medication continued to be administered BID until the resident was discharged. Staff later identified extensive bruising to the resident’s inner thighs, buttocks, and perineal area, and the DON acknowledged that the ongoing concurrent use of Eliquis and Naproxen, despite the intended time-limited order, could have contributed to the bruising.
A resident with encephalopathy related to glioblastoma and moderate cognitive impairment was started on Seroquel by the DON for anxiety and depression despite a psychiatry note stating there was no obvious need for psychotropic intervention and without documentation of behaviors to justify use. No psychopharmacologic informed consent was obtained, and the care plan misidentified Seroquel as an anxiolytic, lacking appropriate assessment, non-pharmacologic interventions, antipsychotic-specific monitoring, or a plan for gradual dose reduction. The DON later acknowledged not knowing why the medication had been started and that there was no documentation supporting the drug regimen.
A resident with severe cognitive impairment and dementia was prescribed Lorazepam for anxiety, but staff failed to document monitoring for adverse side effects after administration. Interviews with the Resident Care Manager and DON confirmed that monitoring was expected but not completed, and the necessary order for monitoring was delayed by over a month.
Surveyors found that the facility did not follow through on recommended gradual dose reductions for psychotropic medications for three residents. In each case, the consulting pharmacist's recommendations were accepted by providers, but either the medication was discontinued without proper communication, or no action was taken to adjust the medication orders, resulting in continued administration of the original doses. Staff interviews confirmed that these recommendations were not properly implemented.
The facility did not ensure that non-pharmacological interventions were attempted before administering PRN pain medications for several residents with complex medical conditions, and failed to provide clear parameters or pain scales for PRN pain medication use. Staff interviews and record reviews confirmed that required interventions and documentation were not consistently completed as ordered.
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