Failure to Monitor Vital Signs for High-Risk Medications
Summary
The facility failed to ensure proper monitoring and adherence to physician-ordered vital sign parameters for residents on high-risk medications. Resident 21 was administered three blood pressure medications on two occasions despite systolic blood pressure readings being below the physician-set parameters. This oversight occurred on specific dates when the systolic blood pressure was documented at 106 and 107, below the hold threshold of 110. Resident 77, who was on multiple medications for congestive heart failure, experienced a similar issue. On a particular date, despite a systolic blood pressure reading of 105, which was below the hold parameter, three medications were administered. This resulted in the resident experiencing very low blood pressure and dizziness, necessitating a transfer to the emergency room later that day. Resident 13, who was on medications for heart failure and irregular heart rhythm, also received medications despite vital signs being below the hold parameters. On two separate occasions, the resident's pulse was documented at 57 and 58, below the hold threshold of 60, yet the medications were administered. Interviews with staff revealed a lack of adherence to the facility's policy requiring vital sign checks and physician notification when parameters are not met.
Penalty
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Surveyors found that multiple residents receiving PRN Ativan for anxiety had physician orders requiring non-pharmacological interventions such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, toileting, and pain management to be used and documented for monitoring. Review of MARs and nursing progress notes showed that PRN Ativan was administered on several occasions without any documentation that these non-pharmacological measures were attempted beforehand. In an interview, the IDON acknowledged that staff did not complete or document the ordered non-pharmacological interventions prior to giving Ativan and noted there was no specific policy addressing this requirement, despite the need to follow physician orders.
A resident with a history of cerebral infarction and asthma was ordered Metoprolol Tartrate for HTN with instructions to hold the dose if SBP was below 110 or HR below 60, and to obtain and record vital signs to guide administration. Over an extended period, no SBP or HR values were documented on the MAR, and staff later confirmed that several doses should have been held but were not. This practice was inconsistent with the facility’s own medication administration policy requiring vital signs to be obtained and medications held when ordered parameters are not met, resulting in the resident receiving medication without adherence to prescribed hold parameters.
A resident without documented psychiatric diagnoses or anxiety symptoms was started on BuSpar and Trazodone following a psychiatric evaluation that relied on the resident’s self-reported sadness, anxiety, and sleep issues, while depression was still being ruled out. Nursing notes did not document the psychiatrist’s assessment or the new psychotropic orders on the day they were made, and there was no clear documentation that the responsible party was notified when BuSpar was initiated. The MAR showed BuSpar was entered and administered twice before being discontinued, and the responsible party later reported not understanding why the medications were started and expressed concern due to the resident’s prior adverse reactions to psychotropics. Interviews with ADONs revealed inconsistent accounts of when and how the responsible party was informed and showed that the rationale for Trazodone was not discussed, contrary to facility policy requiring immediate notification and documentation when there is a change in the resident’s status or treatment.
A resident returned from the ED with new pain and muscle relaxant prescriptions entered as verbal orders from an outside prescriber that were never signed, and there was no documented communication with any facility provider or in-house visit to review these medications, yet staff administered them along with multiple existing antianxiety, muscle relaxant, and analgesic drugs until the resident fell and was later diagnosed in the ED with polypharmacy. Another resident with hypotension had midodrine ordered with instructions to hold the dose when SBP exceeded a specified threshold, but nursing staff repeatedly administered the drug despite SBP readings above that level over several months, contrary to the written parameters. A third resident with ESRD, HTN, and multiple comorbidities was ordered clonidine with hold parameters tied to SBP and pulse, but there was no evidence that BP or HR were obtained for evening doses or that HR was monitored at all during the review period, and the regional nurse confirmed the parameters in the order itself were incorrect, while facility policy required medications to be administered as prescribed.
A resident with insulin-dependent type 2 DM and intact cognition had expired orders for sliding-scale insulin and continuous glucose monitoring, with no new orders entered, while the care plan called for diabetes medications as ordered and monitoring for effectiveness. Over a multi-week period, staff checked the resident’s blood glucose only sporadically, with several days of no checks, and the resident reported that blood sugars were not being monitored throughout the day. An LPN acknowledged checking blood glucose without an active order and described random, unscheduled monitoring, and the DON confirmed there were no current orders for sliding-scale insulin or routine blood glucose checks. The facility’s insulin administration policy offered little guidance on the frequency of blood glucose monitoring.
A resident with hypertension and spinal stenosis had multiple antihypertensive medications ordered with parameters to hold doses and notify the physician or NP if SBP was below a specified threshold, and a PRN opioid ordered only for mild to moderate pain. Review of the MAR showed that all three BP medications were administered when the SBP was below the ordered parameter, without documented provider notification, and a PRN Oxycodone dose was given when the documented pain level was zero. The DON confirmed these medications should only be given within ordered parameters or with documented provider authorization, and facility policy required checking vital sign instructions and documenting the reason for PRN use, which did not occur.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
Surveyors identified a deficiency related to the requirement that each resident’s drug regimen be free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications without prior non-pharmacological interventions. For one resident with hip fracture, dementia, anxiety, and bipolar disorder, the record showed a physician’s order for non-pharmacological interventions (such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, pain medication, and other measures documented in progress notes) to be used for monitoring, and a separate order for PRN Ativan 0.5 mg for anxiety. The MAR documented multiple administrations of PRN Ativan over several days, but review of the MAR and nursing progress notes showed no documentation that non-pharmacological interventions were attempted prior to giving the medication on any of those occasions. Another resident with Alzheimer’s disease and anxiety had physician orders for non-pharmacological interventions similar to those above, as well as an order for PRN Ativan 0.25 mg for anxiety. The MAR showed several PRN Ativan administrations over a three-day period, but the MAR and nursing progress notes lacked documentation of non-pharmacological interventions before the medication was given. A third resident with dementia, hypertension, and incontinence had an order for non-pharmacological interventions and subsequent orders for scheduled and PRN Ativan for anxiety. Review of this resident’s MAR and nursing notes showed PRN Ativan was administered without any documented alternate non-pharmacological interventions beforehand. In an interview, the Interim DON confirmed staff failed to complete or document non-pharmacological interventions prior to administering Ativan and stated there was no specific facility policy requiring such interventions before psychotropic medications, though physician orders were to be followed.
Failure to Follow Ordered Vital Sign Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered parameters for administration of Metoprolol Tartrate. The resident, admitted with diagnoses including cerebral infarction, unspecified and unspecified asthma, uncomplicated, had a physician order dated 01/30/26 for Metoprolol Tartrate 25 mg, 1.5 tablets by mouth twice daily for HTN, with instructions to hold the medication if systolic blood pressure (SBP) was below 110 or heart rate (HR) was below 60. Review of the medication administration record showed no documented SBP or HR from 01/30/26 through 02/26/26, despite the order requiring these parameters to determine whether the medication should be given or held. Pharmacy reiterated the same hold parameters on 02/26/26, yet vital signs were still not documented for the earlier period, and staff interviews confirmed that the medication should have been held for specific doses on 03/10/26 and 03/11/26 but was not. Review of the facility’s Medication Administration Policy dated 08/22/22 showed that staff were required to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs fell outside prescribed parameters, which was not followed in this case. This deficiency was identified for one resident out of five reviewed for unnecessary medications, with a facility census of 92, and was investigated under Complaint Number 2696141.
Failure to Ensure Appropriate Indication and Notification for New Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medications by not establishing and documenting appropriate indications for new psychotropic drugs. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur had no documented history of generalized anxiety disorder, depression, or other psychiatric conditions in the medical record. Review of progress notes over several days showed no signs or symptoms of anxiety and no documentation of referral to psychiatric services. During an admission psychiatric evaluation, the consulting psychiatrist documented the resident’s self-reported sadness, depression, poor sleep, anxiety, and restlessness, diagnosed generalized anxiety disorder, ordered BuSpar 10 mg orally twice daily for anxiety, and Trazodone 25 mg orally every evening while depression was still being ruled out and not listed as a confirmed diagnosis. The nursing documentation did not reflect the psychiatrist’s assessment or the new orders for BuSpar and Trazodone on the date they were made, and there was no documentation of notification of the resident’s responsible party regarding the initiation of BuSpar. The MAR showed the BuSpar order was entered the day after the psychiatric evaluation, and the resident received two doses before discontinuation. The responsible party later reported that the medications were started for an unknown reason, stated the resident had prior adverse reactions to psychotropic medications, and did not want medications that cross the blood-brain barrier. Interviews with the ADONs revealed conflicting accounts about whether and when the responsible party was notified of the new orders, with one ADON stating she did not notify the family by phone and that all communication was in person, and acknowledging that nothing was discussed regarding the rationale for Trazodone. The facility’s policy required immediate notification of the resident and authorized representative, consultation with the practitioner, and documentation in the medical record when there is a change in mental, physical, or psychosocial status, which was not consistently followed in this case.
Failure to Ensure Physician Oversight and Adherence to Medication Parameters
Penalty
Summary
The deficiency involves failures in medication management and physician oversight, resulting in residents receiving unnecessary or improperly monitored drugs. One resident with dementia, muscle weakness, adult failure to thrive, and poly osteoarthritis was admitted with moderate cognitive impairment and required assistance with activities of daily living. After an emergency department visit, this resident was prescribed a lidocaine topical patch and tizanidine for pain and muscle spasms. These new medications were entered as verbal orders from an outside certified nurse practitioner but were never signed, and there was no documented communication with any facility provider about the new medications. Despite the lack of provider sign-off or documented oversight, nursing staff administered these medications along with multiple other antianxiety, muscle relaxant, and pain medications already ordered for the resident. Over several days, the resident received Xanax, baclofen, hydroxyzine, tramadol, Tylenol, lidocaine patch, and tizanidine. Subsequently, the resident experienced a fall and was noted to be slower to respond, with slurred speech. The on-call physician was notified, and the resident was sent to the emergency department, where documentation indicated a diagnosis of polypharmacy with muscle relaxants held and mental status improvement. Review of the medical record confirmed that the emergency room orders from the earlier visit were never signed by the ordering nurse practitioner, there was no documentation of communication with any facility provider regarding the new medications, and no in-house provider visits were documented during that period. The regional nurse confirmed that no documentation could be provided to show provider awareness or oversight of the new medications. A second resident with dementia, hypotension, anxiety disorder, mood disorder, major depressive disorder, and paraphilia had an active care plan for altered cardiovascular status related to hypotension, including medication as ordered by the physician. The physician ordered midodrine 15 mg three times daily with instructions to hold the medication if systolic blood pressure was greater than 110 mmHg. Review of multiple months of MARs showed that midodrine was repeatedly administered when the resident’s systolic blood pressure exceeded 110 mmHg at various morning, afternoon, and evening doses. The regional nurse verified that the resident had systolic blood pressure readings greater than 110 mmHg throughout the review period and that midodrine was not held as ordered. Facility policy required medications to be administered in a safe and timely manner and as prescribed, but the ordered parameters were not followed. A third resident with end-stage renal disease on dialysis, type 2 diabetes, major depressive disorder, opioid dependence, anxiety disorder, and long-term antibiotic use had a care plan for hypertension that included providing antihypertensive medication as ordered, monitoring for side effects, monitoring blood pressure as clinically indicated, and reporting signs of malignant hypertension. The physician ordered clonidine 0.1 mg, three tablets by mouth twice daily, with instructions to hold the medication for systolic blood pressure above 110 mmHg and pulse above 60 bpm. Review of the MAR and vital signs over a one-month period showed that clonidine was scheduled for administration at 10:00 a.m. and 10:00 p.m., but there was no evidence that blood pressure was checked for the evening dose and no evidence that heart rate was obtained at any time during the review period. The regional nurse later verified that the parameters in the order were incorrect and that the medication should have been held for systolic blood pressure below 110 mmHg and pulse below 60 bpm. The facility’s medication administration policy required medications to be administered in accordance with orders, but the required monitoring parameters were not followed or correctly applied.
Failure to Maintain Current Diabetic Orders and Consistent Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s diabetic drug regimen and related monitoring were supported by current physician orders and appropriate blood glucose checks. A resident with type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts was admitted on 12/24/25 and had intact cognition, required substantial assistance with mobility, and used an electric wheelchair. The care plan dated 02/03/26 identified the resident as insulin dependent, with interventions to administer diabetes medications as ordered and monitor side effects and effectiveness. The December 2025 and January 2026 MARs showed an order for Humalog KwikPen per sliding scale from 12/27/25 through 01/17/26 and an order for a Freestyle Libre continuous blood glucose monitoring device from 12/31/25 through 01/13/26, with no new orders entered after those end dates. From 01/19/26 through 02/02/26, blood glucose monitoring for this resident was sporadic and not performed consistently throughout the day, with some days having one or two checks and several days with no checks at all. The resident reported that staff were not checking blood glucose levels throughout the day. An LPN stated she checked the resident’s blood glucose without having an order and described the situation as confusing, with staff checking blood sugars randomly rather than on a scheduled basis, and indicated she would need to contact the physician for order verification. The physician later stated he was unaware there was no order to check blood sugars before meals and that it made no sense to check when there was a plan in place. The DON confirmed there was no new order for a sliding scale or for staff to check the resident’s blood glucose three times a day. Review of the facility’s undated Insulin Administration policy showed it provided little guidance on the frequency of blood glucose monitoring.
Failure to Follow Ordered Parameters for Antihypertensive and PRN Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to administer blood pressure and pain medications within ordered parameters for one resident. The resident was admitted with diagnoses including spinal stenosis, essential hypertension, alcohol dependence, and hyperlipidemia, and had no documented cognitive deficit on the admission MDS. Physician orders included Carvedilol 25 mg twice daily, Hydrochlorothiazide 25 mg daily, and Lisinopril 40 mg daily, all with parameters to hold the medications and notify the physician or NP if the systolic blood pressure (SBP) was less than 110 mmHg, and for Carvedilol also if the pulse was less than 60. Review of the MAR showed that on 01/05/26 all three antihypertensive medications were administered when the resident’s SBP was documented as 108 mmHg, and there was no corresponding documentation in the progress notes that the physician or NP had been notified or had given an order to administer the medications outside the established parameters. The resident also had an order for PRN Oxycodone 5 mg every four hours as needed for mild to moderate pain, defined as pain levels one to five. Review of the MAR revealed that Oxycodone was administered on 01/13/26 when the resident’s documented pain level was zero, indicating administration outside the ordered pain parameters. The DON confirmed in interview that blood pressure medications should not be given when vital signs fall outside ordered parameters unless the physician provides an order, and that PRN pain medications should only be administered within the ordered parameters or with documented physician authorization to deviate. Facility policy on Medication Administration required the nurse to check special instructions and contraindications, including vital signs and other assessments, before giving medications, and to document the reason for administering PRN medications in the MAR and resident chart. These requirements were not followed in this case, resulting in the cited noncompliance.
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