Failure to Document and Implement Repositioning for Resident with Pressure Ulcer
Summary
The facility failed to meet professional standards of quality care for a resident who was admitted with a pressure ulcer in the sacral region. The resident required turning and repositioning every two hours, but the care plans did not specify this requirement, and the medical records did not document that the resident was turned and repositioned as needed. This lack of documentation and care plan specification led to incomplete and inaccurate records of the resident's care. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, and was dependent on assistance for activities of daily living. The resident's condition included a pressure ulcer of the sacral region, which was not properly managed due to the facility's failure to document and implement a consistent turning and repositioning schedule. Interviews with staff, including LVNs, CNAs, and the DON, revealed that while they were aware of the need to turn and reposition the resident every two hours, this was not consistently documented or reflected in the care plan. The deficiency resulted in the potential worsening of the resident's pressure ulcer and the development of new pressure ulcers, contributing to the resident's death from septic shock. The facility's policies and procedures for wound and skin management and turning and repositioning were not adequately followed, as evidenced by the lack of documentation and care plan updates. The facility's failure to adhere to these standards of care and documentation requirements highlights a significant lapse in the quality of care provided to the resident.
Penalty
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A resident with an artificial knee joint and muscle weakness, receiving IV Ampicillin for cellulitis, did not receive IV antibiotic doses at the times ordered by the physician. Facility policy required medications to be administered according to the 5 rights, including correct timing, and the resident’s care plan called for IV therapy as ordered. Surveyors observed that a scheduled midday IV dose had not been given more than an hour after the scheduled time, and documentation showed that multiple midnight doses were also administered late. The DON acknowledged that nurses may delay or late-document medications due to competing care priorities, despite an expectation for timely administration.
Surveyors found that the facility did not meet professional standards when staff failed to clarify and implement provider orders for two residents. One cognitively impaired resident with dementia had a provider note for routine Tylenol for pain, but only a PRN acetaminophen order was in place and the routine order was never entered or administered. Another cognitively impaired resident with diabetes and a right great toe ulcer had an original order for daily Mupirocin ointment and a later wound consultant–driven order for daily Iodosorb treatment, yet both treatments were administered concurrently to the same wound instead of discontinuing the earlier regimen.
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with Alzheimer’s disease and depression exhibited intermittent delusional statements, refusals of medications and care, and occasional yelling or suspiciousness toward staff over several months. Nursing notes documented these behaviors but did not show a comprehensive psychiatric assessment or evidence of a sustained major mood episode. A psychiatric NP subsequently added diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel, despite no prior history of schizoaffective disorder and no detailed evaluation in the record to support the new diagnosis. The resident’s representative reported no known mental health history or hospitalizations and was unaware of the schizoaffective disorder diagnosis, and the DON indicated there was no specific facility policy for schizoaffective disorder.
A nurse failed to follow professional standards and facility policy for medication administration by not properly verifying resident identity before giving scheduled medications. Two severely cognitively impaired roommates were involved; one had orders for oral morphine and levothyroxine, while the other did not. The RN called out one roommate’s name, but when the other responded, the RN proceeded to administer the morphine and levothyroxine without confirming identity using required methods such as the MAR photo or the 5 Rights of Medication Administration. The wrong resident subsequently developed hypotension and profound bradycardia, was sent to the ED, treated with naloxone for opioid poisoning, and diagnosed with accidental opioid poisoning.
The facility failed to meet professional standards of practice when staff did not clarify physician orders for oral medications for a resident who was documented as NPO with dysphagia, esophageal disease, and a gastrostomy. Despite the care plan indicating nothing by mouth, orders for prednisone and magnesium glycinate specified administration by mouth, and nursing staff did not verify or correct these routes before implementation, as required by professional nursing standards.
Failure to Administer IV Antibiotic as Ordered and on Time
Penalty
Summary
The facility failed to ensure that medication services met professional standards of quality for a resident receiving IV antibiotic therapy. Facility policy on medication administration required medications to be given as prescribed and in accordance with the 5 rights of medication administration, including administration within the time frame specified by the physician’s order. The resident had diagnoses including a right artificial knee joint and muscle weakness and had a physician’s order for IV Ampicillin 2 grams every 6 hours for cellulitis, scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM daily. The resident’s care plan identified a risk of complications related to IV therapy for infection, with an intervention for IV therapy as ordered. On one surveyor observation and resident interview, the resident reported not having received the scheduled 12:00 PM IV dose, and the IV antibiotic had still not been administered by 1:13 PM. A nursing progress note later documented that the 12:00 PM dose on that date was given past the administration time at 1:20 PM and marked late on the MAR. Review of the MAR also showed two additional late administrations of the 12:00 AM IV Ampicillin dose on other dates, documented as given at 2:20 AM and 1:56 AM instead of at the scheduled time. The DON stated that nurses may start medication administration but be diverted by other priorities or emergent situations and then sign completion later, and that a progress note should be entered if a medication is administered late or signed late, while also stating the expectation that medications are administered timely and as ordered.
Plan Of Correction
1. Facility cannot correct late administration of IV medication administration for resident identifier #39 during survey. Dr. was notified with no new orders for resident #39. 2. Audit completed, no other residents currently ordered IV medication 3. Education to licensed staff on IV medication administration to include timely administration and proper documentation. 4. Audit of all residents ordered an IV medication will be audited 3 times a week on random administration times for 1 month and then 2 times a week on all residents ordered IV medications for 1 month and then move audit to 1X a week on all residents ordered IV medication for 1 month. Audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Clarify and Update Provider Orders for Pain Management and Wound Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not clarifying and implementing provider orders for two residents. For one resident with dementia who was cognitively impaired and required staff assistance for daily care, a physician progress note documented that the resident was to receive routine Tylenol for pain control. However, the existing physician order listed acetaminophen 500 mg, two tablets every eight hours as needed for pain, and there was no documented evidence that a routine Tylenol order was ever implemented. The Assistant Director of Nursing stated that the routine Tylenol order in the physician’s progress note was missed and therefore was not added to the resident’s medication orders. For another cognitively impaired resident with diabetes mellitus and cellulitis of the right lower limb, the physician initially ordered 2% Mupirocin ointment to be applied once daily to a right great toe ulcer. A subsequent wound consultant note recommended cleansing the right great toe wound with wound cleanser, applying Iodosorb ointment to the wound bed and surrounding callus, and covering it with a dry dressing secured with rolled gauze daily, and a later physician order reflected this Iodosorb-based treatment. Review of the Treatment Administration Record showed that the resident was receiving both the original Mupirocin treatment and the newer Iodosorb treatment to the same right great toe wound. The Director of Nursing confirmed that two wound treatment orders were being carried out concurrently and that the Mupirocin order should have been discontinued in favor of the wound consultant’s recommendation.
Plan Of Correction
Physician orders for R9 Tylenol was addressed on 4/20/2026 upon return from the hospital. R34 treatment orders for toe wound clarified on 4/12/2026. No ill effects noted to either resident. The Clinical and Clinical Reimbursement Consultants re-educated the Minimum Data Set (MDS) Coordinator, Interdisciplinary Team and Administrative Nurses (Director of Nursing, Assistant Director of Nursing, Staff Development/Infection Control Nurse Coordinator, and Nursing Supervisor) regarding resident services provided meeting professional standards, to reflect resident orders for care and services being provided, on May 14 and May 15, 2026. Initial review of physician/provider progress notes for current in-house residents will be completed to ensure resident orders are present per recommendations from 4/23/26 to 5/8/26. The Director of Nursing and/or designee will complete random audits of current in-house resident physician/provider progress notes to ensure orders are present per recommendations as needed weekly for 4 weeks and then monthly for 2 weeks. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Unsubstantiated Schizoaffective Disorder Diagnosis and Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality when assigning a new diagnosis of schizoaffective disorder and initiating an antipsychotic medication for one resident without adequate supporting assessment or documentation. The resident’s clinical record showed existing diagnoses of Alzheimer’s disease, depression, borderline personality disorder, and delusional disorder, with prior PASSAR and admission MDS assessments reflecting depression and dementia/Alzheimer’s disease, and treatment with an antidepressant. Nursing progress notes over several months documented episodes of the resident reporting men causing trouble, believing a man was in her room, and talking about a man wanting to marry her and yelling through the walls, as well as frequent refusals of medications, blood sugar checks, blood pressure checks, insulin, and hygiene care. Additional nursing documentation described the resident as sometimes yelling at staff, being visibly upset by a room move, being leery of staff and asking to see name badges, and making statements that housekeeping had not cleaned her room or that she had not received medications when records indicated that she had. Despite these behaviors and delusional-type statements, there were no other documented behaviors in the nursing progress notes between late April and mid-July beyond refusals of care, expressions of dissatisfaction, and intermittent suspiciousness. The record did not contain a comprehensive psychiatric evaluation establishing that the resident had experienced a major mood episode of uninterrupted duration or otherwise met the diagnostic criteria for schizoaffective disorder. On a psychiatric NP visit for initial psychotropic medication management, the NP added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusions, and ordered Seroquel 25 mg. The resident had no prior history of schizoaffective disorder, and the clinical record lacked an assessment to substantiate this new diagnosis. There was also no documentation that the resident’s mental health history was reviewed with the resident’s representative or that the delusional symptoms were evaluated as a possible progression of Alzheimer’s disease. The resident’s representative later reported that the resident had no known history of mental health disorders or psychiatric hospitalization and was unaware of the schizoaffective disorder diagnosis. The DON stated there was no facility policy specific to schizoaffective disorder and that the facility followed federal regulations.
Medication Error from Failure to Verify Resident Identity Before Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and medication administration were provided in accordance with professional standards of practice and facility policy, specifically the verification of resident identity prior to administering medications. Facility policy on “Medication Administration” required licensed nurses to verify resident identity, including use of the resident’s photograph in the MAR, and to administer medications as ordered and in line with professional standards. State nursing standards cited in the report required RNs to exercise sound nursing judgment, administer drugs as ordered, and follow accepted codes of behavior to assure safe and effective practice, including adherence to the 5 Rights of Medication Administration. Resident 50 and Resident 51 were cognitively impaired roommates, each with severe cognitive impairment as evidenced by low BIMS scores on recent MDS assessments. Resident 50 had physician orders for morphine sulfate oral concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg by mouth daily. Resident 51 had diagnoses including dementia with severe cognitive impairment. On the morning of the incident, an agency RN (Employee 1) entered the shared room, called out Resident 50’s name, and Resident 51 responded. The RN then approached Resident 51, identified the medications prepared for administration (morphine sulfate 0.5 ml and levothyroxine 25 mcg), received an “okay” response from Resident 51, and administered Resident 50’s medications to Resident 51. After leaving the room and returning to the computer to document, the RN realized the medications had been given to the wrong resident. The RN obtained Resident 51’s vital signs, which showed low blood pressure and bradycardia, and emergency services were contacted. Hospital records documented that Resident 51 arrived with abnormal vital signs, including a heart rate of 29 beats per minute and low blood pressure, was alert but disoriented, and was treated with two doses of naloxone for opioid poisoning and profound bradycardia. The resident was diagnosed with accidental opioid poisoning. In a subsequent interview, the RN acknowledged administering medication to the wrong resident and confirmed that she did not follow accepted medication administration practices or the 5 Rights of Medication Administration, leading to the resident receiving another resident’s opioid medication and experiencing adverse clinical effects requiring emergency medical treatment.
Plan Of Correction
1. Facility cannot retroactively correct deficiency as it relates to resident 51 on 4/6/2026 and a medication error. 2. Audited medication errors from 1/1/2026 to current to review root cause of errors. Results have been added to our education component for licensed nurses. 3. As outlined by the self-directed letter, AAE Consulting Services, approved by the Department of Health, will provide facility-wide education on the program called "Professional Standards and Significant medication error standards as well as federal regulations and accompanying guidelines. Education will be provided by AAE Consulting Services to conduct the directed in-service sessions on 4/23/26. Anyone that is unable to attend the 4/23/26 sessions will be required to be completed prior to their next scheduled working shift. A copy of the in-service will also be added to agency orientation documents for review prior to working a shift within the facility. All residents who did not refuse have been issued wrist bands for a secondary identification. Wrist band checks added to residents' TAR per shift to check for placement. All resident pictures for primary identification have been uploaded in their respective EMR's on 4/9/2026. 4. Facility education will be completed biannually with licensed nursing staff for the 5 rights of medication verification. Education will be included in all new licensed nursing staff education during the initial orientation process upon hire. Educations will be audited monthly by the DON/designee and forwarded to the QA committee to ensure compliance with resident identification during medication passes. 5. April 25, 2025
Failure to Clarify Oral Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure physician orders met professional standards of quality by not clarifying medication routes for a resident who was NPO and had swallowing difficulties. Record review showed that a resident readmitted with dysphagia, disease of the esophagus, and a gastrostomy had a nutritional care plan, revised 4/3/26, documenting the resident was NPO (nothing by mouth). Despite this, physician orders directed that prednisone 5 mg be given by mouth daily for renal insufficiency and magnesium glycinate 100 mg be given by mouth at bedtime for insomnia. According to the National Council of State Boards of Nursing, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. On 4/2/26 at 11:32 AM, the DON and CRN confirmed that the resident does not take anything by mouth and acknowledged that the provider’s orders should have been clarified prior to implementation. This failure created the potential for harm if the resident were to receive oral medications despite having difficulty swallowing.
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