Unauthorized Administration of Chemical Restraints
Penalty
Summary
A deficiency occurred when a nurse administered over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents without physician orders and for non-medical reasons, such as to induce sleep during the night shift. The facility's policy clearly states that residents have the right to be free from chemical restraints imposed for discipline or staff convenience, and that any use of such medications must be authorized in writing by a physician for a specific and limited period or in an emergency, with proper documentation and immediate physician consultation for chemical restraints. However, the investigation revealed that the nurse gave these medications to residents without proper authorization, and the medications were not ordered for those residents at the time of administration. The incident was brought to light when staff members reported unusual resident behaviors, such as increased confusion, excessive drowsiness, decreased participation in activities, and changes in mood or behavior that correlated with the nights the nurse in question worked. Statements from staff and residents indicated that some residents received medications they were not supposed to get, and in some cases, residents could recall being given something to help them sleep. The facility's investigation found that bottles of Melatonin were placed in medication carts and that a significant number of pills were unaccounted for. The nurse involved denied giving sleep aids but later admitted to administering Melatonin and Benadryl to residents without current orders. Clinical record reviews confirmed that the affected residents did not have active orders for the medications administered. Several residents experienced notable changes in their cognitive and physical status, such as increased confusion, inability to walk, and behavioral changes. The Director of Nursing verified that the allegations of abuse were substantiated, and it was unclear how many residents received unauthorized medications. The facility's failure to ensure that medications were only administered as ordered by a physician and not for staff convenience resulted in a violation of residents' rights to be free from chemical restraints and abuse.
Plan Of Correction
N: 0204 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved ones. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for Melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits are conducted twice a week for two weeks, then weekly for a total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.