Failure to Follow Protocol After Resident Fall with Head Injury
Summary
Staff failed to follow professional standards of care after a resident with dementia, heart failure, and severe cognitive impairment experienced a witnessed fall with a head injury. The resident, who was known to be at risk for falls and had a history of recent illness, was observed by a nurse aide to become dizzy, spin, and fall, striking their head on the floor. Following the fall, the resident exhibited altered mental status, was unable to follow commands, and staff were unable to obtain vital signs. Despite these significant changes in condition and the presence of a head injury, the supervising RN directed staff to move the resident from the floor into a wheelchair and then into bed, rather than leaving the resident in place and awaiting EMS as per standard protocols for suspected head or spinal injury. Multiple staff, including an LPN and the APRN, later acknowledged that the resident should not have been moved given the circumstances. Facility policy and medical references reviewed also indicated that residents with head injuries and neurological compromise should not be moved and should be referred immediately for emergency care. The resident was eventually transferred to the hospital by EMS after oxygen was applied, but expired a few hours later. Documentation and interviews confirmed that the decision to move the resident was made by the RN, and that other staff present did not question this directive, despite recognizing it was not consistent with best practice or facility policy for post-fall care involving head injury and altered mental status.
Penalty
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The facility failed to safeguard resident medications and ensure professional standards of practice when an LPN diverted multiple non‑narcotic medications belonging to several residents, many with impaired cognition and complex medical conditions. Pharmacy and law enforcement investigations found numerous patient‑specific blister packs, pill bottles, and a transdermal patch in the LPN’s possession that had been removed from the facility without detection or reporting. Although an investigator met with the Administrator and DON and confirmed that the medications were tied to current and former residents, the Administrator did not submit a self‑reported incident, and the DON reported limited knowledge of the situation. This occurred despite a written policy requiring reporting and thorough investigation of misappropriation of resident property, including diversion of medications.
A nurse documented the administration of insulin for a resident before actually giving the medication, contrary to facility policy and standard practice. The resident, who had multiple chronic conditions and intact cognition, received the medication after it was already signed off in the MAR. This was confirmed through observation, record review, and staff interviews.
A facility failed to obtain psychiatric progress notes for a resident, resulting in a missed diagnosis of schizoaffective disorder. The resident's medical record and care plan were not updated, and medication orders were inaccurately transcribed, leading to the resident receiving extra doses of Abilify. The DON confirmed these deficiencies, highlighting a lack of follow-up with the psychiatrist's office and errors in medication transcription.
A resident with type II diabetes mellitus did not receive appropriate diabetic care at the facility. Despite a care plan outlining necessary interventions, there was no blood glucose monitoring or antidiabetic medication administered from June to late October. The resident was hospitalized with high blood glucose levels, and it was revealed that the facility had not implemented the required care plan interventions. Staff interviews confirmed the oversight, and the Medical Director was unaware of the diabetes diagnosis.
An LPN failed to follow standard nursing practices for safe medication administration, affecting two residents. The LPN did not use the MAR during administration, signing off medications before actually administering them. This led to an incorrect dose being given to one resident, violating the facility's policy.
A medication administration error occurred when a resident was given Zyprexa 10 mg intended for another resident. The medication, initially refused by one resident, was not returned to the pharmacy and was later administered to another resident experiencing escalated behaviors. This error was confirmed by the RN Unit Manager.
Failure to Safeguard and Report Diversion of Resident Medications
Penalty
Summary
The deficiency involves the facility’s failure to safeguard resident medications and ensure services met professional standards of quality when an LPN diverted non‑narcotic medications belonging to multiple residents without the knowledge of facility administration. Record review showed that ten residents, most with impaired cognition and multiple medical diagnoses, had prescribed medications documented on their MARs, including hydroxyzine for anxiety, several antibiotics (Macrobid, cephalexin, cefadroxil) for treatment or prophylaxis, Levsin as needed, prednisone daily, and a scopolamine patch. These medications were ordered and recorded as being administered over various time frames, but were later found in the possession of the LPN outside the facility. A State Board of Pharmacy investigation, initiated after notification from local law enforcement, determined that the LPN had 31 blister packs of various medications, two pill bottles containing white powder, and one transdermal patch, all identified as patient‑specific medications belonging to approximately 20 residents, including the ten residents cited in the deficiency. The medications were able to be removed from the facility without anyone noticing or reporting the theft. An email from the Pharmacy Board to the DON on the date of the investigation stated that a former employee was found in possession of numerous patient‑specific medications and that these medications had been removed from the facility without detection or reporting to the Board of Pharmacy. Interviews with facility leadership showed that administration did not recognize or act upon the diversion as a reportable incident involving misappropriation of resident property. The Administrator stated that when the Pharmacy Board investigator came to the facility, she was not given resident names or specific medications and therefore did not complete a self‑reported incident to the State agency, and she left the meeting believing the diversion had occurred at another facility. The DON, hired after the diversion period, reported she had been kept in the dark about the investigation and could not provide adequate information. These actions and inactions occurred despite a facility policy on Abuse Prohibition, revised in 2022, which required that allegations of misappropriation of resident property, including diversion of resident medications, be reported and thoroughly investigated.
Medication Administration Documentation Prior to Actual Administration
Penalty
Summary
Staff failed to document the administration of medications in accordance with acceptable standards of practice. Specifically, a registered nurse documented the administration of Lantus insulin for a resident prior to actually administering the medication. The facility's policy and the statements from both the Director of Nursing and the Administrator confirmed that the expected process is to administer the medication before documenting it on the Medication Administration Record (MAR). However, the nurse signed off on the MAR before giving the medication, which was acknowledged as a mistake during an interview. The resident involved had a medical history including cerebral palsy, heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus, and was cognitively intact at the time of the incident. The nurse administered the resident's scheduled dose of Lantus insulin, but the MAR indicated it was documented as given before the actual administration. This discrepancy was observed and confirmed through interviews and record review.
Failure to Obtain Psychiatric Notes and Transcribe Medication Orders
Penalty
Summary
The facility failed to ensure that psychiatric progress notes were obtained from an outside provider for a resident, leading to a lack of awareness of a new diagnosis of schizoaffective disorder. The resident, who was admitted with diagnoses including encephalopathy, PTSD, unspecified psychosis, major depressive disorder, and anxiety disorder, did not have the new diagnosis added to their medical record or care plan. The facility did not follow up with the psychiatrist's office to receive chart notes from the resident's visits, resulting in the omission of the schizoaffective disorder diagnosis from the resident's records. Additionally, the facility failed to accurately transcribe changes to the resident's psychiatric medications. An order was written to continue Abilify and start Olanzapine, but the facility's records showed discrepancies in the medication administration. The resident received 12 extra doses of Abilify due to inaccurate transcription of the physician's order. The Director of Nursing confirmed these issues, acknowledging that the facility did not obtain the necessary chart notes and failed to accurately transcribe medication orders.
Failure to Provide Diabetic Care for Resident
Penalty
Summary
The facility failed to provide diabetic care in accordance with professional standards for a resident diagnosed with type II diabetes mellitus. The resident was admitted with multiple diagnoses, including type II diabetes mellitus, but there was no evidence of blood glucose monitoring or administration of antidiabetic medications from June to late October. The care plan included interventions for diabetes management, but these were not implemented, leading to the resident experiencing significantly elevated blood glucose levels. The resident was sent to the hospital in late October due to unsteadiness and shortness of breath, where it was discovered that their blood glucose level was in the mid-500s. The hospital recommended insulin administration, which had not been provided at the facility. Upon return to the facility, the resident's blood glucose levels remained high, ranging from 153 mg/dL to 536 mg/dL over the following weeks. Interviews with the resident and staff revealed that the diagnosis of diabetes was added in June, but the necessary monitoring and medication orders were not put in place. The Director of Nursing and the MDS nurse confirmed that the diabetes diagnosis was added upon the resident's return from the hospital in June, but the physician was not notified, and the care plan interventions were not executed. The Medical Director was unaware of the diabetes diagnosis and stated that appropriate orders would have been made if informed. The facility's policy on diabetes management emphasizes the importance of monitoring and medication management, which was not adhered to in this case.
Failure in Safe Medication Administration Practices
Penalty
Summary
The facility failed to ensure standard nursing practices were followed for safe medication administration, affecting two residents. For Resident #8, the Licensed Practical Nurse (LPN) #383 documented administering medications including Calcium with Vitamin D, Cranberry, Lexapro, and Lubiprostone at 7:48 A.M. However, during an observation at 8:10 A.M., it was revealed that LPN #383 was not using a computer or paper physician orders during the medication administration process. Instead, she stated that she reviewed the computer before starting her rounds and signed off on the medications before actually administering them. This practice was contrary to the facility's policy, which required the use of the Medication Administration Record (MAR) during administration to ensure the five rights of medication administration were followed. Similarly, for Resident #44, LPN #383 documented administering medications including Magnesium Oxide, a multivitamin, Vitamin D3, and Pregabalin at 7:43 A.M. An observation at 8:16 A.M. showed that LPN #383 was again not using the MAR during administration. She admitted to signing off the MAR before administering the medications and subsequently administered an incorrect dose of Vitamin D3, giving 10 micrograms instead of the prescribed 25 micrograms. This was a direct violation of the facility's medication administration policy, which mandates the use of the MAR to verify the correct medication, dose, and other critical factors during administration.
Medication Administration Error
Penalty
Summary
The facility failed to maintain professional standards of quality when a medication intended for one resident was administered to another. Resident #74, who had diagnoses including dementia, type two diabetes mellitus, bipolar disorder, and schizoaffective disorder, refused a one-time order for the antipsychotic medication Zyprexa 10 mg via intramuscular injection on 08/07/24. This medication was supposed to be returned to the pharmacy but was instead placed in a box for return and remained in the medication storage room. On 08/12/24, Resident #33, who had diagnoses including epilepsy, high blood pressure, schizoaffective disorder, and traumatic brain injury, was experiencing escalated behaviors. A one-time order for Zyprexa 10 mg via IM injection was received for Resident #33. However, due to the medication not being returned to the pharmacy, Resident #33 was administered the Zyprexa 10 mg that was originally ordered for Resident #74. This incident was confirmed by RN UM #101, who acknowledged that the medication intended for Resident #74 was used for Resident #33.
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