Failure to Obtain Physician's Orders for Pacemaker Checks
Summary
The facility failed to obtain physician's orders for pacemaker checks for a resident, as required by both the Pennsylvania Nursing Practice Act and the facility's own policy. The resident, who was cognitively impaired and had a cardiac pacemaker, was admitted to the facility with a care plan indicating the need for pacemaker checks per physician's order. However, there was no documented evidence in the resident's clinical record of any physician's order for these checks, nor any documentation that the checks had been completed since the resident's admission. Interviews with the Nursing Home Administrator and the Registered Nurse Assessment Coordinator confirmed the absence of documented evidence for the pacemaker checks. The RNAC also noted that the resident had missed a scheduled pacer clinic appointment. This oversight indicates a failure to adhere to the facility's policy and the resident's care plan, which required routine pacemaker checks to ensure the device's proper functioning.
Penalty
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A resident with osteomyelitis, CHF, and atrial fibrillation was admitted on apixaban 2.5 mg PO BID. A subsequent physician order for apixaban 2.5 mg was incorrectly transcribed as 12.5 mg PO BID, and a nurse later signed off administration of the erroneous 12.5 mg dose. The resident had recently reported new left leg swelling and redness and had a negative ultrasound for DVT, but there was no documented physician order to increase apixaban. The ADON reported that the nurse who transcribed the order mistakenly changed the dose and that the nurse administering the medication did not recognize that the new dose would require five tablets instead of one, resulting in a documented medication order and MAR entry that did not meet professional standards of quality.
A resident with severe cognitive impairment and urinary incontinence had a physician order for UA with C&S, but no order specifying straight catheterization. An LPN, unable to obtain a clean-catch specimen, attempted an in-and-out catheterization without a catheter order and called two CNAs to assist when the resident became combative and verbally objected. The CNAs held the resident’s arms and legs while the LPN inserted the catheter, after which bright blood was observed in the urine. Later, the resident experienced painful urination, hematuria, and blood clots, leading to transfer to the ER and return with an indwelling catheter and blood in the urine. Facility leadership and the Medical Director confirmed that professional standards require a specific catheter order and stopping the procedure if the resident refuses or shows distress, and acknowledged that these standards were not followed.
Staff failed to follow professional standards for medication administration and documentation for a resident receiving a Rivastigmine transdermal patch for dementia. Review of MARs showed unclear and conflicting removal times for the 24‑hour patch and inconsistent adherence to the physician’s bedtime order, with two different removal times documented on both the March and April records. In addition, staff did not document the anatomical sites where patches were applied, despite the DON stating that documenting patch sites was important. During a med pass observation, interviewed LPNs affirmed the importance of following physician orders, yet the MAR entries did not clearly demonstrate compliance with those orders or with accepted standards for transdermal patch use.
Staff failed to clarify PRN orders and consistently monitor blood pressure for a resident receiving Midodrine via PEG tube for orthostatic hypotension and Clonidine for HTN, both ordered every eight hours with specific SBP parameters. Clinical record review showed no evidence that blood pressure was taken every eight hours to determine the need for these PRN medications. An LPN stated that blood pressure should be checked before administering such medications, and a regional clinical leader acknowledged that PRN Midodrine had been cited previously and that PRN Clonidine orders were unusual and required clarification.
Facility staff failed to follow professional standards by not documenting or transcribing a physician's order for Benadryl after a resident's allergic reaction, administering medications outside the scheduled window for another resident, and not documenting resident-to-resident altercations in the clinical records for three residents. Nursing and administrative staff confirmed these actions did not meet basic nursing practice requirements.
An LPN administered Breo Ellipta inhalation powder to a resident with COPD but did not prompt the resident to rinse and spit their mouth after use, as required by the medication's instructions to reduce the risk of oropharyngeal candidiasis. The LPN acknowledged not providing the prompt, citing the resident's lack of cooperation. This failure to follow professional standards was confirmed during observation and interview.
Medication Transcription Error for Anticoagulant Order
Penalty
Summary
Facility staff failed to ensure that a medication order for an anticoagulant met professional standards of quality when a nurse inaccurately transcribed a physician’s order for apixaban. The resident involved had been admitted after an acute care hospital stay with diagnoses including right 5th finger osteomyelitis/septic arthritis requiring IV therapy, congestive heart failure, and atrial fibrillation, and had a BIMS score of 11/15 indicating moderately impaired cognitive abilities for daily decision-making. The resident was admitted with an order for apixaban 2.5 mg by mouth twice daily. A new order was written on 3/13/26 for apixaban 2.5 mg, but it was transcribed in the record as “Give 12.5 mg by mouth twice daily,” changing the dose from 2.5 mg to 12.5 mg. On 3/14/26, a nurse signed off that 12.5 mg of apixaban had been administered, reflecting the incorrect transcribed dose. The physician’s progress note from 3/13/26 documented that the resident had presented with new left leg swelling and redness and had undergone an ultrasound to rule out a blood clot, which was negative, but there was no order from the physician to increase apixaban to 12.5 mg. During an interview, the ADON stated that the nurse who transcribed the order mistakenly changed the apixaban dose and that the nurse who administered the medication did not notice that the new ordered dose would have equaled five tablets instead of one. The ADON further stated that an audit later showed that the 12.5 mg strength was associated with a new order for Aldactone, not apixaban, confirming that the transcription error had occurred in the medication orders for this resident.
Unauthorized Straight Catheterization and Use of Physical Restraint to Obtain Urine Specimen
Penalty
Summary
Facility staff failed to follow professional standards of practice when obtaining a urine specimen for Resident #42, who had severe cognitive impairment and was always incontinent per the most recent MDS. The physician’s order for the resident specified a UA with culture and sensitivity every shift for three days but did not include an order to obtain the specimen via straight catheterization. Despite this, on the evening of 01/28/2025, an LPN attempted an in-and-out catheterization to collect the urine sample after determining the resident was unable to urinate into a urinal. During the procedure, bright blood was noted in the urine sample, and the catheter was removed. The LPN notified the on-call NP and documented that the resident appeared anxious but stable. According to the facility’s internal investigation and staff statements, the LPN called two CNAs into the room when the resident became combative during the catheterization attempt. The resident’s friend, who was present initially, reported that the resident said “Don’t do that” and crossed his legs when the nurse attempted to insert the catheter, and that staff then asked her to step into the hallway. While in the hallway, she heard the resident yelling. CNA statements and the facility’s synopsis of the event documented that the CNAs held the resident’s arms and legs while the LPN inserted the catheter in order to obtain the urine specimen. The facility’s investigation concluded that the resident was restrained during the procedure and that this was a common practice according to the LPN’s own statement, despite the resident’s right to refuse care. Following the catheterization, the resident was later noted around 5:00 a.m. on 01/29/2025 to have discomfort and pain with urination, hematuria, and blood clots in the brief. Vital signs were documented as stable, and the on-call NP was notified and ordered transfer to the ER. The resident returned from the hospital later that day with an indwelling urinary catheter and blood in the urine. The facility’s grievance report documented that the resident and representative alleged a catheter was used for a urine sample against the resident’s will, resulting in injury and hospitalization. The facility’s Medical Director and nursing leadership, when interviewed by surveyors, stated that professional standards required a physician’s order for straight catheterization if a clean-catch specimen could not be obtained and that the procedure should be stopped and the physician notified if the resident refused or showed distress. They acknowledged that the LPN and CNAs did not follow these standards when they proceeded with catheterization without a specific catheter order and while the resident was being held down.
Failure to Follow Professional Standards for Transdermal Patch Administration and Documentation
Penalty
Summary
Facility staff failed to ensure professional standards of quality in medication administration for one cognitively intact resident with multiple chronic conditions, including Parkinson's disease, atrial fibrillation/flutter, chronic heart failure, type 2 diabetes, and hypertension. Review of the closed electronic clinical record and the March and April 2025 Medication Administration Records (MARs) showed that medications were not administered as ordered by the physician. Specifically, the Rivastigmine 9.5 mg/24 hr transdermal patch, ordered to be applied at bedtime for dementia and removed per schedule, had unclear and inconsistent removal times documented. The March MAR showed an order start date of 3/15/2025 and discontinue date of 3/27/2025, with entries to remove the patch at both 1:18 p.m. and 7:59 p.m., and to apply the patch at 8:00 p.m. The April MAR similarly listed two removal times, 2:33 p.m. and 7:59 p.m., with application at 8:00 p.m. The MARs also lacked documentation of the anatomical sites where the Rivastigmine patches were applied, despite the DON acknowledging that documenting patch sites was important so staff would know where patches had been placed. During medication pass observations, interviewed LPNs stated it was important for nurses to administer medications and follow physician orders, yet the MAR documentation did not clearly reflect adherence to those orders or to professional standards for transdermal patch use. Reference materials cited in the report, including Lippincott Nursing Procedures and external guidance on transdermal patches, emphasized the need to follow physician orders, facility policies, and proper documentation, as well as the importance of rotating patch sites, underscoring the deficiencies identified in the resident’s medication administration records.
Failure to Clarify PRN Blood Pressure Medication Orders and Monitor Blood Pressure
Penalty
Summary
Facility staff failed to clarify and appropriately implement physician orders for as-needed blood pressure medications for one resident. The resident had a physician order for Midodrine 10 mg via PEG tube every eight hours as needed for orthostatic hypotension, to be given when systolic blood pressure (SBP) was under 100 mmHg, and a separate order for Clonidine to be given by mouth every eight hours as needed for hypertension, to be given when SBP was over 170 mmHg. Review of the clinical record did not show that the resident’s blood pressure was being taken every eight hours to determine whether either of these PRN medications was needed. During an interview, an LPN stated that when a medication requires a blood pressure check, the nurse should take the blood pressure and then administer or hold the medication according to the physician’s order. In another interview, the regional director of clinical services reported that the facility had previously been cited regarding Midodrine orders and had addressed this with physicians by changing such orders from PRN to scheduled doses with hold parameters, and also stated that it was unusual to have a PRN order for Clonidine and that these orders needed clarification. Administrative staff, including the administrator, DON, and regional director of operations, were informed of these findings, and no additional information was provided before survey exit.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for five residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, failed to document an assessment of an allergic reaction after the resident was served fish, and did not update the care plan to address allergies. Interviews and record reviews confirmed that the allergic reaction was not properly documented, and there was no evidence of the medication being administered or the event being recorded in the clinical record. Another resident received medications outside of the scheduled administration window on multiple occasions, as shown by medication administration records. The medications involved included midodrine, sennosides-docusate sodium, carbamazepine, and pregabalin. Nursing staff confirmed that medications should be administered within a two-hour window for resident safety, but records showed doses given significantly outside this timeframe. Additionally, for three separate residents involved in resident-to-resident altercations, staff failed to document the incidents in the clinical records as required by professional nursing standards. Facility synopses described the altercations and subsequent assessments, but there were no corresponding progress notes in the residents' clinical records. Interviews with nursing staff and administration confirmed that documentation of such events is a basic nursing practice and should include a description of the incident, steps taken to ensure safety, and assessment results.
Failure to Ensure Resident Rinsed Mouth After Inhaled Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of care during medication administration for one resident diagnosed with chronic obstructive pulmonary disease (COPD). During a medication pass observation, an LPN administered Breo Ellipta (fluticasone furoate-vilanterol) inhalation powder to the resident, followed by other prescribed oral medications. The LPN did not prompt or request the resident to rinse and spit their mouth after using the inhaler, despite the medication's pharmacy label and manufacturer's instructions clearly stating that rinsing the mouth after each use is necessary to reduce the risk of oropharyngeal candidiasis. Upon inspection of the medication and interview with the LPN, it was confirmed that the LPN did not ask the resident to rinse their mouth, stating that the resident does not cooperate with this instruction. The clinical record included a physician's order for daily use of Breo Ellipta for COPD, and the manufacturer's instructions were available on the medication cart. The deficiency was reviewed with facility administration, and no additional information was provided before the end of the survey.
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