F0684

D

Failure to Follow Medication Parameters and Assess Unexplained Eye Injury

Plainfield, Indiana Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and ordered parameters for monitoring and medication administration for two residents. For one resident with type 2 diabetes mellitus, stage 3 chronic kidney disease, heart failure, edema, and a cardiac pacemaker, there was a physician order dated 3/18/25 to check heart rate daily and monitor for signs and symptoms of altered cardiac output or pacemaker malfunction. Record review for November 2025, December 2025, and January 2026 showed no documented heart rate measurements for this resident during those months, despite the standing order. The Regional Reimbursement Nurse confirmed that the ordered daily heart rate checks were not completed as required.

For another resident diagnosed with vascular dementia, essential HTN, and stage 2 chronic kidney disease, the facility failed to follow ordered blood pressure and heart rate parameters when administering antihypertensive medications. A physician order dated 3/18/25 directed administration of losartan 100 mg daily with instructions to hold the dose for systolic BP less than 110. The eMAR showed that on multiple dates in December 2025 and January 2026, the resident’s systolic BP readings were below the ordered threshold (ranging from 94 to 107), yet losartan was still administered. A separate physician order dated 5/8/25 for metoprolol tartrate 12.5 mg twice daily required holding the dose for systolic BP less than 100 or HR less than 60. On one January 2026 date, the resident’s systolic BP was 96, but the metoprolol dose was administered. The DON acknowledged that medications should have been held when physician-ordered parameters indicated they should not be given.

A separate deficiency concerns the facility’s failure to assess and document an unexplained injury and to follow its incident/accident reporting policy for another resident. This resident, with Alzheimer’s disease, anxiety disorder, major depressive disorder, and severe cognitive impairment, was found by his wife with a swollen, darkly bruised left eye. She reported that staff could not explain the cause of the injury, had not notified her of any incident, and had not planned diagnostic tests to assess the injury. Observation confirmed swelling and discoloration of the left eye. The clinical record contained a general progress note stating the left eye was puffed and dark in color and that staff would continue to monitor, but there was no documented assessment of vital signs, neurological status, or the left orbital area at the time the injury was discovered. The record also lacked documentation of physician notification, notification of appropriate personnel, or notification of the spouse, despite a facility policy requiring immediate assessment, use of a neurological assessment tool for suspected head trauma or unwitnessed falls, and documentation and notifications following unexplained injuries.