Failure to Meet Professional Standards: Staff Sleeping, Medication Administration Errors, and Non-Compliance with Physician Orders
Penalty
Summary
Staff on the overnight shift were observed sleeping while on duty, contrary to facility policy and professional standards. Multiple residents reported that staff routinely sleep during the 11:00 P.M. to 7:00 A.M. shift, and surveyors directly observed several CNAs and a nurse asleep in darkened dining rooms on both the first and second floors. Time card reviews showed that these staff members did not clock out for breaks, and interviews confirmed that staff were not following the required procedures for taking breaks or remaining alert and available to residents during their shifts. During a medication pass, a nurse dispensed medications without triple-checking them against the physician's orders, as required by standard practice. The nurse relied on memory and handwritten lists provided by a unit manager, rather than verifying each medication with the Medication Administration Record (MAR) or the physician's orders. The nurse admitted to not performing the required checks, and the DON confirmed that the expected practice is to check each medication three times for accuracy before administration. For a resident with end stage renal disease and an arteriovenous fistula, staff failed to follow physician's orders that specified no blood pressure should be taken on the right arm. Medical record review showed multiple instances where blood pressure readings were documented as being taken on the right arm, despite clear orders and facility policy prohibiting this practice for residents with AV fistulas. The DON and unit manager acknowledged that the orders were not followed in these cases.