Failure to Adhere to Professional Standards in Medication Administration and Monitoring
Summary
The facility failed to meet professional standards of nursing practice by not properly obtaining accurate orthostatic blood pressure readings for two residents. For Resident 25, the orthostatic blood pressure readings were suspiciously identical on multiple occasions, indicating a potential error in measurement. The Director of Staff Development noted that the readings for both lying and sitting positions were the same on several dates, which is unlikely as there should always be a difference. Similarly, for Resident 1, the orthostatic blood pressure readings were also found to be the same for lying and sitting positions on different dates, and a Licensed Vocational Nurse admitted to not knowing how to properly take these measurements. The facility also failed to ensure that medication was administered to the correct site as ordered by the physician for Resident 96. The resident was supposed to receive Diclofenac Sodium External Gel 1% applied to both knees for pain, but it was instead applied to the right shoulder. The Licensed Vocational Nurse acknowledged the error and admitted to not realizing there was no order for the shoulder application, which could potentially lead to adverse reactions or harm to the resident. Additionally, the facility did not administer Midodrine HCI according to the physician's parameters for Resident 55. The medication was given even when the systolic blood pressure was above the specified limit, and the 10:00 p.m. dose was administered despite instructions not to give it after the evening meal or less than 3-4 hours before bed. The Director of Nursing confirmed that the medication should have been held when the blood pressure was above the limit and that the 10:00 p.m. dose should not have been given, as it could cause potential harm to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, License Vocational Nurse (LVN) 4 received one-on-one in-servicing with return demonstration by the Director of Nursing and Director of Staff Development to ensure she understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. On 3/17/24, Resident 55 started Midodrine HCI 5 mg, give 5 milligrams (mg) orally every 8 hours for hypotension; hold if systolic (top number in a blood pressure reading) blood pressure (SBP) is greater than 110, not to be taken after the evening meal or less than 3-4 hours before bed. Resident 55 was noted to have received medication Midodrine HCI 5 mg outside of parameters. No adverse or negative outcome was noted for Resident 55 as a result of this deficient practice. On 3/10/25, Licensed Vocational Nurse (LVN) 4 received an on-one-one in-service on administering medication per physician order. There were no negative or adverse outcomes for Resident 96 as a result of this deficient practice. On 3/14/25, LVN 4 received an order from Resident 96's Primary Physician for pain medication (Diclofenac Sodium External Gel 1%) to be administered to the left shoulder. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The residents affected by this deficient practice experienced no negative outcome. On 3/10/25, the Director of Nursing conducted interviews on residents who have topical pain medication orders to ensure residents are receiving topical pain medication as ordered. No other residents were affected by this deficient practice. On 3/24/25, the Medical Records Director conducted an audit on residents with blood pressure medication orders to ensure medication is being administered within parameters ordered by the physician. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses on the facility's policy and procedure titled, "Blood Pressure, Measuring" with emphasis on orthostatic hypotension being defined as 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, note the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter for 3 months to ensure residents' orthostatic hypotension monitoring is being recorded accurately. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on testing and taking of vital signs, upon which administration of medications or treatments are conditioned, performing required tests, and recording results. The in-service also included when administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record. The in-service emphasized reviewing the resident's MAR for allergies and/or special considerations for administration, including vital sign parameters and lab results as appropriate. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with blood pressure medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. On 3/21/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to LVNs and RNs, on the facility's policy and procedure titled, "Medication - Administration," with emphasis on providing professional standards of practice for safe administration of medications for residents in the facility, including following information about any medication they are administering, the drug's route of administration, the drug's indication for use, and desired outcome. The in-service also emphasized the seven "rights" of medication when administering medication: right medication, right amount, right resident, right time, right route, right indication, and right outcome, and the "rule of 3" (performing 3 checks): comparing the physician's order, pharmacy label, and medication administration record (MAR). On 3/31/25, the Director of Nursing/ designee revised orders for residents with pain medication being administered topically to include documentation requirements for where the licensed nurse administered the medication to ensure medication is being administered to the site as ordered. The Medical Records Director will conduct an audit on the following parameters for administering medication for residents with topical pain medication orders daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' parameters are being followed. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, following parameters for administering medication for residents with blood pressure medication orders, and medication administration related to pain medication being administered to the correct site as ordered for three months or until compliance is met.
Penalty
Resources
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The facility failed to meet professional standards for wound care and feeding tube management. Two residents with skin tears had wound care entered and carried out without proper provider notification and without documentation of assessments or family notification, while a cognitively intact resident with a feeding tube was documented as receiving Glucerna enterally even though staff and the resident stated it was being taken orally and no enteral supplies were observed.
Failure to Follow Physician Orders for Insulin and BP Medication: Two residents had medication orders not carried out as directed. One resident with diabetes had Novolog and Lantus insulin doses held for blood sugar readings without documented MD orders to hold them. Another resident with HTN had Metoprolol held with an order for VS monitoring and provider review, but the required VS were not documented and the medication was restarted without communication with the MD.
Failure to Assess Pain and Maintain PICC Dressing Care: One resident developed abdominal pain, received Norco without a documented pain assessment or follow-up assessment, then had vomiting and left for hospital evaluation the same day. A second resident with a PICC line had a dressing that was not changed as ordered; the infusion center found multiple layers of tape over an old dressing and sent the resident for ER evaluation and redressing. The DON acknowledged the missed documentation and missed dressing changes.
Medication administration documentation was not completed correctly for two residents. One resident with DM, schizoaffective disorder, depression, anxiety, GERD, hyperlipidemia, neuropathy, and pain had multiple missed doses later signed off on the MAR, including one gabapentin entry that was pre-signed before it was due. Another resident with schizophrenia had multiple missed doses for psychotropic, cardiac, thyroid, eye drop, and other medications, and the paper MAR showed later sign-offs and pre-signing of timolol, gabapentin, and Valium before they were due. Staff and the DON acknowledged that medications were documented after the fact and, in some cases, before administration.
A former RN failed to follow professional nursing standards when she gave a resident edible marijuana that was not ordered by the physician. An LPN observed the RN cut up what appeared to be candy in the resident’s room, then identify it as marijuana gummies and place pieces within the resident’s reach. The resident had osteoarthritis, mild cognitive impairment, anxiety disorder, and PRN pain orders including tramadol, acetaminophen, heat or ice, and morphine.
A resident with moderate cognitive impairment and diagnoses including a femoral neck fracture and pain had Norco delivered to the facility, but the narcotic was not properly signed into the cart or reconciled. When the resident later requested PRN pain medication, none was available, and the facility’s investigation found that an RN failed to complete the narcotic sign-in process and the medication was never located.
Failure to Document and Follow Ordered Wound and Tube Feeding Care
Penalty
Summary
The facility failed to provide services that met professional standards of quality for resident skin issues and feeding tube management. For one resident with metabolic encephalopathy, dysphagia, dementia, aphasia, and weakness, staff found a skin tear on the bilateral forearms with dressings already in place and entered wound care orders in the computer without documenting a progress note or contacting a provider to report the findings or confirm the order. The resident’s record showed prior and current wound care orders for skin tears, but there was no documentation in the progress notes from early June through mid-August regarding notification to a provider or the resident representative about the wounds or dressings. A second resident, admitted for orthopedic aftercare and with diagnoses including weakness, difficulty walking, COPD, anxiety, depression, heart failure, PTSD, and excoriation disorder, had a skin tear to the left lateral ankle. The wound care nurse entered a verbal order for wound care, and the MAR/TAR documented daily dressing care, but the progress notes contained no documentation of the skin tear, notification to family or provider, or treatment orders. The resident was cognitively intact, and during observation had a bordered gauze dressing to the left lower extremity. The facility policy required verification of the provider’s order and timely documentation of assessments, observations, and services provided. For a third resident with a feeding tube, intracerebral hemorrhage, cerebral edema, diabetes, morbid obesity, atrial fibrillation, gastrostomy status, and hypertension, the record showed an order for bolus Glucerna 1.5 by enteral route when meals were eaten at less than 75%, with water flushes before and after bolus feedings. However, staff documented the Glucerna as being administered enterally on the MAR/TAR while also stating that the resident was drinking the Glucerna orally. The resident stated she was taking medications and Glucerna by mouth and nothing was going through the feeding tube, and no feeding pump or enteral supplies were observed. The DON stated that if the resident preferred to take the feeding orally, the physician should be notified and the order updated, but the record showed the ordered route was not followed as documented.
Failure to Follow Physician Orders for Insulin and Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for two residents. For one resident with diabetes who was cognitively intact and receiving insulin, physician orders included Novolog insulin with meals and Lantus insulin every 12 hours. The medication administration record showed multiple instances in which Novolog was held for blood sugar readings of 98, 86, 84, and 85 mg/dl, and Lantus was held for blood sugar readings of 71 and 94 mg/dl. The Nursing Home Administrator confirmed that the insulin doses were held without physician orders to do so and without documented evidence that the physician had given such orders. For another resident with diagnoses including hypertension, the physician ordered Metoprolol Tartrate 25 mg every morning and bedtime, then later ordered staff to hold the medication, obtain vital signs twice daily for seven days, and have the provider assess the appropriateness of Metoprolol by reviewing the resident's vital signs. There was no documented evidence that the ordered vital signs were obtained, and the medication was resumed without communication with the physician. The Director of Nursing confirmed that the facility failed to communicate with the provider before restarting the Metoprolol order.
Failure to Assess Pain and Maintain PICC Dressing Care
Penalty
Summary
Licensed nursing staff failed to provide nursing services in accordance with professional standards of quality for two residents. One resident was admitted with diagnoses including high blood pressure, a history of falling, and adult failure to thrive, and was her own health care decision maker. On 6/23/26, she developed abdominal pain at 2:45 p.m. and was given Hydrocodone Acetaminophen (Norco) 5/325 mg, but there was no documentation of a pain assessment or pain level before or after the medication was administered. RN A confirmed that no documentation was completed regarding the resident’s pain assessment, and the medication administration record did not contain an entry showing that Norco had been administered. The same resident continued to have pain, had one episode of vomiting, requested transfer to the hospital, and left the facility at 5:05 p.m. the same day. The DON confirmed that the resident reported abdominal pain, had green-colored vomiting, received Norco as ordered, and then requested hospital transfer for evaluation. The DON later stated that documentation of the resident’s pain should have been entered in the nursing progress notes and that ongoing assessments were required, including use of a pain scale and a full gastrointestinal assessment with bowel sounds and abdominal palpation. A second resident was admitted with diagnoses including UTI, liver disease, and AKI and had physician orders for PICC line dressing changes on admission, then weekly and as needed, and for PICC site assessment every shift. The infusion center documented on 7/20/26 that the resident’s PICC dressing had multiple layers of tape over the original dressing dated 6/27/26, and the infusion center RN recommended emergency room evaluation and a dressing change. The resident stated that staff were not changing the PICC dressing as often as they should have been, and the DON acknowledged that the dressing changes were not performed as required.
Medication Administration Documentation Not Completed Correctly
Penalty
Summary
The facility failed to follow its Medication Administration Policy and did not ensure timely and correct documentation of medication administration for two residents. The policy required staff to follow the six rights of medication administration, administer medications before documenting them, and report and document refusals or adverse effects. Surveyors found that medication administration records for both residents showed multiple missed opportunities that were later signed off as administered on paper MARs, and in some instances the documentation was entered before the medication was due. One resident had diagnoses including diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, GERD, hyperlipidemia, polyneuropathy, and low back pain. Review of the July 2026 eMAR showed multiple missed administrations across several scheduled medications, including atorvastatin, ezetimibe, Farxiga, gabapentin, Invega, lisinopril, mirtazapine, omeprazole, sertraline, clonazepam, topiramate, fiber, and tramadol. The paper MAR printed later showed that a CMT signed off as administering all of the missed opportunities for many of these medications, and also pre-signed gabapentin before the medication was due. The CMT stated that the documentation was completed on the paper MAR after the fact and that staff should never document a medication as given before it was actually administered. The second resident had diagnoses including schizophrenia, and the July 2026 eMAR showed missed administrations for atorvastatin, furosemide, latanoprost, levothyroxine, olanzapine, Paxil, trazodone, brimonidine, Depakote, medroxyprogesterone, timolol, gabapentin, and Valium. The paper MAR received for this resident showed only one page and included signatures indicating that missed doses had been administered, while timolol, gabapentin, and Valium were pre-signed before they were due. Staff interviews confirmed that the internet outage affected documentation, that some staff used hotspots while others used paper MARs, and that the DON directed staff to sign the paper MARs later. The DON acknowledged that staff should not document medication administration before the medication is actually administered and that the residents should have had completed documentation at the time of administration.
Unauthorized Marijuana Given to Resident
Penalty
Summary
The facility failed to ensure staff provided care and services according to professional standards of quality for one resident reviewed for medication administration. Resident 4 was admitted with diagnoses including osteoarthritis, mild cognitive impairment, and anxiety disorder, and had a care plan addressing pain management, including monitoring for side effects of pain medication and offering non-pharmacological pain interventions. The resident also had physician orders for tramadol, acetaminophen, ice or heat application, and morphine sulfate oral concentrate as needed for pain. A former RN provided Resident 4 with edible marijuana that was not ordered by the resident’s physician. An LPN who was receiving orientation from the RN observed the RN cut up what appeared to be candy in the resident’s room, then heard the RN identify it as edible marijuana gummies and acknowledge that she was giving them to the resident. The LPN observed the RN place pieces of the gummies within the resident’s reach. The RN later stated she had provided edible marijuana to the resident and had not given it to other residents.
Failure to Secure and Track a Resident’s Narcotic Medication
Penalty
Summary
The facility failed to maintain professional standards of nursing practice for the storage, tracking, and reconciliation of a scheduled controlled substance for one sampled resident. The resident had been admitted with diagnoses including left femoral neck fracture, muscle wasting and atrophy, and unspecified pain, and the admission MDS reflected a BIMS score of 9, indicating moderate cognitive impairment. Review of the facility policy showed it did not specifically address new narcotic medication security after delivery from the pharmacy, and the DON stated the facility did not have a policy for checking in narcotic medications or a drug diversion policy. The resident’s Norco 7.5 mg 30-count blister pack was delivered to the facility, but it was not properly signed into the medication cart and was later found missing when the resident requested PRN pain medication and none was available. Interviews and the facility’s investigation showed an LPN received the narcotic medication and asked a KMA to assist with logging it in, the KMA placed it in the cart and told the oncoming RN that the RN would need to complete the blue and white narcotic sheets, and RN 2 failed to sign the medication into the cart as requested. The investigation also noted RN 2 had suspicious behavior, had accidentally taken home a resident’s medication on another occasion, and the missing Norco was never located.
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