Improper Administration of Fentanyl Patch
Summary
The facility failed to ensure proper administration of pain medication for Resident B, who was diagnosed with respiratory failure, COPD, opioid dependence, and hepatitis C. A Qualified Medication Aide (QMA 2) administered a Fentanyl transdermal patch on the wrong day, contrary to the physician's order. The order specified that the patch should be applied every three days, with the old patch removed and disposed of properly. However, QMA 2 replaced the patch a day early, on the evening of 9/28/24, without notifying licensed nursing staff, a supervisor, or the physician. This error was discovered when Resident B informed the staff the following day. The Director of Nursing (DON) confirmed that the error occurred and that the Fentanyl patch was not scheduled to be changed until the next day. The facility's policy on medication administration, which requires verification of the correct time for medication administration, was not followed. The incident was related to a complaint, and the facility's policy dated 12/1/07 was reviewed, indicating the need for adherence to medication administration protocols.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with atrial fibrillation, hypertension, and hypotension had a physician order for metoprolol succinate ER 25 mg with instructions to hold the dose if BP was below 100/50 mm/Hg and/or pulse was below 60 bpm. Review of the MAR showed the medication was administered on two occasions when the resident’s documented BP and/or pulse were below the ordered parameters. The DON confirmed the medication should not have been given under those conditions, contrary to the facility’s policy on following physician orders and parameters.
An LPN was hired and allowed to work independently on multiple units without verification of an active nursing license, contrary to facility policies and job requirements that mandate proof of current licensure and adherence to professional standards and state regulations. Review of the personnel file showed no documentation of a valid license, and the Administrator acknowledged that licensure had not been confirmed before the LPN provided nursing care to residents.
A resident reported that an LPN, with whom the resident had an ongoing conflict, did not personally administer prescribed medications and instead directed a nurse aide to hand the medications to the resident. Facility policy requires that only state-licensed or permitted personnel prepare and administer medications. The LPN confirmed instructing an aide to give the medications while the LPN remained nearby, and neither the LPN nor the resident could identify the aide involved. This resulted in medications being administered by unlicensed staff, contrary to facility policy and regulatory requirements.
QMAs performed and documented wound care outside their legal scope of practice for a resident with a recurrent left great toe wound involving partial and full thickness loss. The MAR contained orders to cleanse and paint the toe with povidone iodine and leave it open to air on day and evening shifts, and multiple QMAs documented completing these treatments over several months. In interviews, QMAs stated they understood they were only allowed to apply creams and powders and not to treat stage 1 or open wounds, and one QMA admitted signing for treatments she did not perform while another stated she signed after watching a nurse perform the care. The DON believed QMAs could complete the toe treatment because it was open to air, but the state QMA scope of practice limited QMAs to minor skin conditions (including stage I decubitus) and prohibited them from administering treatments for advanced skin conditions such as stage II–IV decubitus ulcers or documenting medications not personally administered.
Surveyors determined that the facility did not ensure all licensed nursing staff held appropriate CPR certification for healthcare providers. Review of the facility’s CPR policy showed it required American Red Cross or American Heart Association BLS/CPR with hands-on training. However, review of records for three licensed nurses (two LPNs and one RN) revealed they only had online, non-healthcare-provider CPR courses without a hands-on component. The NHA confirmed that these nurses did not have current, hands-on CPR certification consistent with accepted national standards.
A resident with Parkinson’s disease and a deep brain stimulator (DBS) had physician orders and a care plan directing that the DBS be charged on specific days using a chest-placed charging disk, yet the resident reported that staff did not know how to charge it and that it was sometimes not charged. Multiple LPNs and an RN stated they had not been inserviced on how to use, read, or charge the DBS, did not know how to confirm it was charging, and relied on the resident or family for guidance, while describing various Parkinson’s symptoms they observed when the DBS was not charged. The DON and ADON acknowledged there had been no formal staff education on the DBS, and although a written DBS policy existed, there was no indication it had been implemented through staff training, despite expectations from the medical director and neurologist’s office that staff would be educated on device use and related symptoms.
Failure to Follow Hold Parameters for Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order with specific vital sign parameters for a resident’s cardiac medication. The resident had diagnoses including atrial fibrillation, hypertension, and hypotension. A physician order dated 3/14/26 directed that metoprolol succinate ER 25 mg be given once daily by mouth, with instructions to hold the medication if the resident’s blood pressure was less than 100/50 mm/Hg and/or pulse was less than 60 beats per minute. Review of the March 2026 Medication Administration Record showed that on 3/17/26 the resident’s blood pressure was documented as 96/48 mm/Hg and pulse as 54 beats per minute, yet the metoprolol succinate ER was administered. Further review of the Medication Administration Record indicated that on 3/19/26 the resident’s pulse was documented as 56 beats per minute, and the metoprolol succinate ER was again administered despite the physician’s hold parameters. During an interview, the DON confirmed that the metoprolol succinate ER 25 mg should not have been given on those dates due to the low pulse rate and/or low blood pressure, as specified in the physician’s order. The facility’s current policy titled “Following Physician orders/Parameters,” dated April 2024, states that its purpose is to administer resident care in a safe and effective manner and to follow physician orders and ordered parameters, which was not done in this case.
Unverified LPN Licensure Resulting in Unqualified Nursing Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by qualified personnel in accordance with each resident’s written plan of care. During review of an employee file for an LPN hired in late September and terminated in early November, surveyors found no documentation of an active LPN license. The Administrator reported that the LPN had been hired without verification of licensure and that the facility was unable to confirm that this individual ever held an active nursing license. The Administrator further indicated that the LPN worked on all units in the facility and provided dates on which the LPN worked independently after an initial orientation period. The facility’s own documents required proof of current licensure upon application for employment and at least annually thereafter, and the LPN job description specified that the position required a current, unencumbered state LPN license. Additional policies and role descriptions referenced that an LPN must accept assignments consistent with education, training, and competency, and adhere to professional standards, facility policies, and applicable state laws and regulations. Despite these written requirements, the LPN’s personnel file lacked evidence of a valid license, and the Administrator acknowledged that licensure had not been verified before the LPN was allowed to work and provide nursing care to residents on multiple units.
Unlicensed Staff Directed to Administer Medications During Nurse–Resident Conflict
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were administered by a licensed nurse in accordance with the resident’s plan of care and facility policy. The facility’s medication administration policy states that only persons licensed or permitted by the state may prepare, administer, and document the administration of medications. A grievance filed by Resident R1 indicated that a licensed nurse (Employee E4) did not personally give the resident their medications. The grievance documentation showed that Employee E4 reported the resident would not accept medications from them, and the Medication Administration Audit Report reflected that Employee E4 was removed from Resident R1’s nursing unit on February 21, 2026. Resident R1 reported an ongoing conflict with Employee E4 and stated that the nurse gave the resident’s medications to a nurse aide to hand to the resident because they were not getting along. In a telephone interview, Employee E4 confirmed instructing a nurse aide to administer medications to Resident R1, stating that the nurse remained nearby while the aide handed the medications to the resident. Employee E4 also stated they did not know the name of the nurse aide involved. Resident R1 similarly did not recall the aide’s name and expressed not wanting the aide to get in trouble. These findings show that an unlicensed nurse aide was directed to administer medications, contrary to the facility’s policy and state requirements that only licensed or permitted personnel may perform this task.
QMAs Performed and Documented Wound Care Outside Scope of Practice
Penalty
Summary
Surveyors identified a deficiency in which Qualified Medication Aides (QMAs) performed and/or documented wound treatments outside their legal scope of practice for a resident with a left great toe wound. Resident D had multiple diagnoses, including chronic systolic heart failure, chronic pain syndrome, venous thrombosis history, malnutrition, atherosclerosis of the lower extremities, and restless legs syndrome. A NP wound note from late December documented that an earlier toe wound had resolved but a new wound on the left great toe had developed, initially suspected as an arterial ulcer and later classified as trauma-related. The wound was described as full thickness loss, dry, without drainage, and measured 0.8 cm x 1.2 cm x 0.1 cm. The January MAR ordered cleansing of the left great toe with povidone iodine and leaving it open to air on the day shift, with monitoring for infection or worsening, and QMA 5 documented completion of this treatment on two dates. In late January, nursing documentation indicated the resident’s left toe wound had reopened, was bleeding, and was wrapped with gauze, though the resident would not allow measurement. A February NP wound note recorded that the left great toe wound had reopened with partial thickness loss and measured 0.7 cm x 1.0 cm x 0.1 cm. The February MAR contained orders to cleanse the left great toe with povidone iodine and leave it open to air every day and evening shift, later specifying to cleanse and paint with povidone iodine and leave open to air, with monitoring for signs of infection or worsening. QMAs 5, 7, and 9 documented on multiple dates in February that they completed these wound treatments. A subsequent NP wound note in late February described the wound as stable, scabbed, with partial thickness loss and measuring 0.6 cm x 0.7 cm x 0.1 cm. In March, the MAR continued the order to cleanse and paint the left great toe with povidone iodine and leave it open to air every day and evening shift, with monitoring instructions, and QMAs 5, 7, and 9 again documented completion of these treatments on multiple dates. During interviews, QMA 5 stated that QMAs were allowed to apply creams and powders but not to treat any stage 1 or higher wounds, and acknowledged it was possible she signed for Resident D’s wound treatments even though the wound had worsened and QMAs had stopped doing the treatment. QMA 9 stated QMAs could apply creams and powders but not treat stage 1 or open wounds, and reported that she watched a nurse complete Resident D’s wound treatment but signed it off in the MAR herself, believing she could apply povidone iodine to a wound. QMA 7 similarly indicated QMAs were not allowed to complete treatments above a stage 1 or on open wounds and said she had not completed the resident’s wound treatments because he had a “crater” on his toe. The DON, however, indicated QMAs could not complete wound treatments above stage 2, wounds with bandages, or invasive treatments, but believed QMAs could complete this resident’s wound treatment because the toe was left open to air. The state QMA scope of practice obtained from IDOH specified that QMAs may apply topical medications only to minor skin conditions, including stage one decubitus ulcers, and may not administer treatments involving advanced skin conditions such as stage II–IV decubitus ulcers, and also may only document medications they personally administered, not those given by another person or not administered at all.
Failure to Ensure Licensed Nursing Staff Maintain Proper Hands-On CPR Certification
Penalty
Summary
Surveyors found that the facility failed to ensure that certain nursing personnel maintained current CPR certification for healthcare providers that included a hands-on session, as required by facility policy and accepted national standards. The facility’s written policy on emergency procedures for cardiopulmonary resuscitation required staff to obtain and maintain American Red Cross or American Heart Association certification in Basic Life Support/CPR. The Nursing Home Administrator provided a list of currently employed LPNs and RNs, and review of CPR certification cards for three of 27 licensed nurses (two LPNs and one RN) showed that their certifications were from online-only CPR classes intended for non-healthcare providers and did not include any hands-on component. In an interview, the Nursing Home Administrator confirmed that the facility had not ensured these nurses held appropriate, hands-on CPR certification for healthcare providers in accordance with accepted national standards. No specific residents, medical histories, or clinical events related to CPR use were described in the report; the deficiency was identified through policy review, staff record review, and staff interviews.
Lack of Staff Competency in Managing Resident’s Deep Brain Stimulator
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were knowledgeable and competent in the use and monitoring of a deep brain stimulator (DBS) for a resident with Parkinson’s disease. The resident’s face sheet documented diagnoses of Parkinson’s disease and a DBS, and the care plan included an approach to charge the DBS on specified days by placing a round disk on the right side of the chest for approximately two hours or until fully charged. The physician’s orders and the treatment administration record also directed that the DBS be charged three times weekly on night shift. Despite these written directions, the resident reported that staff were supposed to charge his DBS but did not know what they were doing and that sometimes his DBS was not charged. Multiple staff interviews confirmed a lack of formal in-service training and inconsistent knowledge about how to operate the DBS charger, how to verify that it was charging, and what symptoms the resident would exhibit if the DBS was not charged. Several LPNs and an RN stated they had not been inserviced on how to use, read, or charge the DBS device and did not know how to tell if it was charging or what symptoms to look for when it was not charged. One LPN reported learning from the resident’s family and the resident himself, rather than from facility training, and others stated that the family or the resident handled the charging. Staff described various observations when the DBS was not charged, including increased tremors, difficulty swallowing, coughing while eating, delayed or slurred speech, and slow movements, but this knowledge was informal and not based on structured education. Leadership interviews further demonstrated the absence of a systematic training process. The DON, who had been in the role for over ten years, acknowledged she had not inserviced staff on how to use the resident’s DBS and did not know the full extent of symptoms that could occur if it was not charged. The ADON recalled being shown how to charge and read the device by the resident’s family at the time of admission, rather than through a facility-led process. The neurologist’s medical assistant and the medical director both stated that when the DBS is not charged, the resident’s Parkinson’s symptoms increase, such as tremors, slurred speech, shuffling gait, and out-of-control tremors, and both expected staff to be educated on device use and symptoms. A DBS policy dated 1/2013 referenced following manufacturer’s instructions and charging as recommended by the doctor but did not bear the facility’s name, and there was no evidence in the report that this policy had been implemented through staff training.
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