Failure to Administer Ordered Medications and Notify Providers Resulting in Resident Death
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received prescribed medications in accordance with physician orders. The resident was admitted from a local hospital after a prolonged hospitalization for acute on chronic respiratory failure with hypercapnia, acute respiratory distress, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, among other diagnoses. Hospital discharge instructions and the facility’s October physician order sheet show that the resident was to receive multiple routine medications, including oxygen at 5 L via nasal cannula, diuretics (torsemide, spironolactone, acetazolamide), bronchodilators and nebulizer treatments (albuterol, ipratropium‑albuterol, arformoterol, Breztri), steroids (prednisone, fluticasone), psychotropic medication (clonazepam), and several other maintenance medications and supplements. Facility policy required that physician orders be entered within one hour of admission, that pharmacy be contacted after 4:00 p.m. for new admissions, and that medications be obtained from the emergency drug kit or STAT Safe if not yet delivered. Despite these orders and policies, the resident’s Medication Administration Record shows that on two consecutive days after admission, the resident did not receive a wide range of ordered medications at scheduled times (8:00 a.m., 12:00 p.m., and 4:00 p.m.). Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol, clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol. These doses were documented by the LPN as “unavailable,” yet there is no documentation in the medical record that the physician was notified of the missed doses or that nursing management was informed. The facility had an electronic STAT Safe with several of the resident’s ordered medications stocked, including albuterol nebulizer solution, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN later stated she did not obtain medications for the resident from this machine on the days in question. Interviews confirmed that required escalation and communication did not occur. The LPN reported that when new admissions arrive, other staff typically enter orders and that medications are usually delivered between 8:00 p.m. and 10:00 p.m., but she stated the resident’s medications had not arrived and that the resident did not receive medications on the two days prior to death. She acknowledged she did not notify the physician or nursing management that the resident had not received any medications, including breathing treatments, diuretics, heart failure medications, or prednisone, and could not explain why she did not administer certain medications that had been delivered by pharmacy before the resident’s death. The attending physician and an advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not administered; the physician stated the medications, including multiple diuretics, nebulizer treatments, and steroids, should never have been placed on hold and that he expected medications to be available on the evening of admission or to be notified to modify the treatment plan. Pharmacy records showed that many of the resident’s medications were delivered late in the evening and early morning following admission, but the resident still did not receive them as ordered. The resident was last noted as alert with shortness of breath at times and requiring BiPAP and nebulizer treatments with oxygen; later, staff found the resident without respirations or pulse when attempting to administer medications, and the death certificate lists acute on chronic congestive heart failure and acute on chronic diastolic heart failure with COPD as contributing conditions. The facility’s failure to follow physician orders, obtain and administer available medications, and provide appropriate monitoring and response resulted in actual harm and death and was cited at the Immediate Jeopardy level. The facility’s own policies and available resources underscore the inactions that led to the deficiency. The Medication Availability policy directed staff to enter orders promptly, contact pharmacy after 4:00 p.m. for new admissions, use the emergency drug kit or STAT Safe for needed medications, and obtain STAT or backup pharmacy delivery when medications were not in stock, with all administrations documented in the EMAR. The pharmacy’s posted hours and cutoff times, along with the STAT Safe inventory list, showed that many of the resident’s ordered medications were accessible through the automated dispensing cabinet. Nonetheless, the LPN did not use the STAT Safe to obtain medications, did not document any attempts to secure medications beyond marking them as unavailable, and did not escalate the issue to the DON or physician. The DON later verified that the resident did not receive multiple ordered medications on the days prior to death and that she had not been informed of the unavailability or non‑administration of these medications. These documented failures in medication procurement, administration, and communication formed the basis of the cited deficiency and Immediate Jeopardy determination.
Removal Plan
- Director of Nursing reviewed all residents to confirm they are receiving prescribed medications as ordered.
- All licensed nurses were educated by the Director of Nursing and provided access/instructions on how to obtain unavailable medications from the facility emergency medication kit (STAT Safe).
- Regional Nurse Consultant educated the Director of Nursing on medication administration and medication availability processes.
- As part of QA activities, match-back audits are completed for medication availability.
- All new admissions are reviewed using a checklist to ensure medications are available and orders are in place; this checklist is reviewed during the clinical QA meeting.
- Licensed nursing staff were educated by the Director of Nursing on adherence to physician orders, timely resident assessment and documentation, physician notification when an ordered medication dose is missed, and immediate notification/escalation to facility nursing administration for any medication administration issue.
- An audit tool/process was created by the Director of Nursing to ensure compliance with medication administration and availability, assessment and documentation, physician notification, and escalation to nursing administration.
- Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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