Multiple Failures in Medication Management, Order Implementation, and Behavior Monitoring
Summary
The deficiency involves multiple failures to meet professional standards of quality related to medication security, protection of resident health information, implementation of physician orders, behavior monitoring, and medication administration. During early morning rounds on the first floor, a medication cart on B-Wing was observed unlocked and unattended, and an unlocked laptop displaying resident-specific information was left at the doorway of a resident room. During a medication pass with an RN, the medication cart and computer screen were repeatedly left open, unlocked, and unattended in various rooms and in the first-floor lobby, with resident information visible. On a later date, another medication cart on the second floor B-Wing was also observed open and unattended. The RN and an LPN both acknowledged that facility expectations require medication carts and computer screens to remain locked when not in use. Another deficiency involved failure to implement a physician order for a diagnostic test. A physician ordered a Complete Blood Count (CBC) for a resident with pneumonia to monitor the resident’s condition and guide treatment. A subsequent medical record review showed that this laboratory order was not carried out as written. The ADON explained that physicians enter lab orders, nurses transcribe them, and the 11:00 PM–7:00 AM shift is responsible for ensuring completion of lab tests unless the order is STAT. The ADON later confirmed that the CBC for this resident was not completed as ordered and stated that the reason for the failure was unknown. Additional deficiencies were identified in behavior monitoring and documentation for residents with psychiatric or behavioral diagnoses and those receiving psychotropic medications. One resident with depression, anxiety, and insomnia had an order for behavior monitoring every shift, and the TAR showed multiple dates and shifts with documented behavior frequencies, including a high number of behaviors on one date; however, there were no corresponding progress notes describing the types of behaviors or interventions used. Facility staff stated that when behaviors are documented on the TAR, it is the process to write a progress note describing the behaviors and interventions, and to complete an SBAR and notify the provider if behaviors persist or are new. The DON confirmed that progress notes should be written when behaviors escalate and that the TAR only records the number of episodes, not the behavior details, and could not explain the absence of progress notes for the documented behavior episodes. For another resident receiving Duloxetine, Escitalopram, and Olanzapine for depression and anxiety, review of the MAR showed that the medications were administered as ordered, but there was no documentation of behavior monitoring or effectiveness monitoring for the antipsychotic therapy. The ADON stated that effectiveness is to be monitored using behavior monitoring flow sheets and progress notes, but review of the record confirmed that no such documentation existed for this resident despite ongoing psychotropic use. A further resident with vascular dementia with psychotic disturbance, mood disturbance, and anxiety, and known behaviors such as yelling and screaming at others and a preference for personal space, had no documented behavioral assessment, no behavior monitoring tool in place, and no care plan interventions addressing these behaviors in the medical record. A separate deficiency involved improper medication administration when a resident was found with a Lidocaine patch on the mid-back that had been dated the previous day. The wound nurse identified the patch as a Lidocaine patch, but review of the resident’s medication orders and medical record revealed no physician order for a Lidocaine patch and no documentation of its application. The unit manager confirmed that the resident had a Lidocaine patch without a corresponding physician order, and the DON confirmed that the resident should not have had the patch because a physician order is required and administration must be documented on the MAR. The facility’s Nursing Policies and Procedures: Medical Management Program require documentation of medications administered according to state and federal requirements, including correct physician orders and diagnoses for each medication, and specify that for transdermal patches the application site must be documented and sites rotated, which was not done in this case.
Penalty
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The facility failed to meet professional standards for wound care and feeding tube management. Two residents with skin tears had wound care entered and carried out without proper provider notification and without documentation of assessments or family notification, while a cognitively intact resident with a feeding tube was documented as receiving Glucerna enterally even though staff and the resident stated it was being taken orally and no enteral supplies were observed.
Failure to Follow Physician Orders for Insulin and BP Medication: Two residents had medication orders not carried out as directed. One resident with diabetes had Novolog and Lantus insulin doses held for blood sugar readings without documented MD orders to hold them. Another resident with HTN had Metoprolol held with an order for VS monitoring and provider review, but the required VS were not documented and the medication was restarted without communication with the MD.
Failure to Assess Pain and Maintain PICC Dressing Care: One resident developed abdominal pain, received Norco without a documented pain assessment or follow-up assessment, then had vomiting and left for hospital evaluation the same day. A second resident with a PICC line had a dressing that was not changed as ordered; the infusion center found multiple layers of tape over an old dressing and sent the resident for ER evaluation and redressing. The DON acknowledged the missed documentation and missed dressing changes.
Medication administration documentation was not completed correctly for two residents. One resident with DM, schizoaffective disorder, depression, anxiety, GERD, hyperlipidemia, neuropathy, and pain had multiple missed doses later signed off on the MAR, including one gabapentin entry that was pre-signed before it was due. Another resident with schizophrenia had multiple missed doses for psychotropic, cardiac, thyroid, eye drop, and other medications, and the paper MAR showed later sign-offs and pre-signing of timolol, gabapentin, and Valium before they were due. Staff and the DON acknowledged that medications were documented after the fact and, in some cases, before administration.
A former RN failed to follow professional nursing standards when she gave a resident edible marijuana that was not ordered by the physician. An LPN observed the RN cut up what appeared to be candy in the resident’s room, then identify it as marijuana gummies and place pieces within the resident’s reach. The resident had osteoarthritis, mild cognitive impairment, anxiety disorder, and PRN pain orders including tramadol, acetaminophen, heat or ice, and morphine.
A resident with moderate cognitive impairment and diagnoses including a femoral neck fracture and pain had Norco delivered to the facility, but the narcotic was not properly signed into the cart or reconciled. When the resident later requested PRN pain medication, none was available, and the facility’s investigation found that an RN failed to complete the narcotic sign-in process and the medication was never located.
Failure to Document and Follow Ordered Wound and Tube Feeding Care
Penalty
Summary
The facility failed to provide services that met professional standards of quality for resident skin issues and feeding tube management. For one resident with metabolic encephalopathy, dysphagia, dementia, aphasia, and weakness, staff found a skin tear on the bilateral forearms with dressings already in place and entered wound care orders in the computer without documenting a progress note or contacting a provider to report the findings or confirm the order. The resident’s record showed prior and current wound care orders for skin tears, but there was no documentation in the progress notes from early June through mid-August regarding notification to a provider or the resident representative about the wounds or dressings. A second resident, admitted for orthopedic aftercare and with diagnoses including weakness, difficulty walking, COPD, anxiety, depression, heart failure, PTSD, and excoriation disorder, had a skin tear to the left lateral ankle. The wound care nurse entered a verbal order for wound care, and the MAR/TAR documented daily dressing care, but the progress notes contained no documentation of the skin tear, notification to family or provider, or treatment orders. The resident was cognitively intact, and during observation had a bordered gauze dressing to the left lower extremity. The facility policy required verification of the provider’s order and timely documentation of assessments, observations, and services provided. For a third resident with a feeding tube, intracerebral hemorrhage, cerebral edema, diabetes, morbid obesity, atrial fibrillation, gastrostomy status, and hypertension, the record showed an order for bolus Glucerna 1.5 by enteral route when meals were eaten at less than 75%, with water flushes before and after bolus feedings. However, staff documented the Glucerna as being administered enterally on the MAR/TAR while also stating that the resident was drinking the Glucerna orally. The resident stated she was taking medications and Glucerna by mouth and nothing was going through the feeding tube, and no feeding pump or enteral supplies were observed. The DON stated that if the resident preferred to take the feeding orally, the physician should be notified and the order updated, but the record showed the ordered route was not followed as documented.
Failure to Follow Physician Orders for Insulin and Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for two residents. For one resident with diabetes who was cognitively intact and receiving insulin, physician orders included Novolog insulin with meals and Lantus insulin every 12 hours. The medication administration record showed multiple instances in which Novolog was held for blood sugar readings of 98, 86, 84, and 85 mg/dl, and Lantus was held for blood sugar readings of 71 and 94 mg/dl. The Nursing Home Administrator confirmed that the insulin doses were held without physician orders to do so and without documented evidence that the physician had given such orders. For another resident with diagnoses including hypertension, the physician ordered Metoprolol Tartrate 25 mg every morning and bedtime, then later ordered staff to hold the medication, obtain vital signs twice daily for seven days, and have the provider assess the appropriateness of Metoprolol by reviewing the resident's vital signs. There was no documented evidence that the ordered vital signs were obtained, and the medication was resumed without communication with the physician. The Director of Nursing confirmed that the facility failed to communicate with the provider before restarting the Metoprolol order.
Failure to Assess Pain and Maintain PICC Dressing Care
Penalty
Summary
Licensed nursing staff failed to provide nursing services in accordance with professional standards of quality for two residents. One resident was admitted with diagnoses including high blood pressure, a history of falling, and adult failure to thrive, and was her own health care decision maker. On 6/23/26, she developed abdominal pain at 2:45 p.m. and was given Hydrocodone Acetaminophen (Norco) 5/325 mg, but there was no documentation of a pain assessment or pain level before or after the medication was administered. RN A confirmed that no documentation was completed regarding the resident’s pain assessment, and the medication administration record did not contain an entry showing that Norco had been administered. The same resident continued to have pain, had one episode of vomiting, requested transfer to the hospital, and left the facility at 5:05 p.m. the same day. The DON confirmed that the resident reported abdominal pain, had green-colored vomiting, received Norco as ordered, and then requested hospital transfer for evaluation. The DON later stated that documentation of the resident’s pain should have been entered in the nursing progress notes and that ongoing assessments were required, including use of a pain scale and a full gastrointestinal assessment with bowel sounds and abdominal palpation. A second resident was admitted with diagnoses including UTI, liver disease, and AKI and had physician orders for PICC line dressing changes on admission, then weekly and as needed, and for PICC site assessment every shift. The infusion center documented on 7/20/26 that the resident’s PICC dressing had multiple layers of tape over the original dressing dated 6/27/26, and the infusion center RN recommended emergency room evaluation and a dressing change. The resident stated that staff were not changing the PICC dressing as often as they should have been, and the DON acknowledged that the dressing changes were not performed as required.
Medication Administration Documentation Not Completed Correctly
Penalty
Summary
The facility failed to follow its Medication Administration Policy and did not ensure timely and correct documentation of medication administration for two residents. The policy required staff to follow the six rights of medication administration, administer medications before documenting them, and report and document refusals or adverse effects. Surveyors found that medication administration records for both residents showed multiple missed opportunities that were later signed off as administered on paper MARs, and in some instances the documentation was entered before the medication was due. One resident had diagnoses including diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, GERD, hyperlipidemia, polyneuropathy, and low back pain. Review of the July 2026 eMAR showed multiple missed administrations across several scheduled medications, including atorvastatin, ezetimibe, Farxiga, gabapentin, Invega, lisinopril, mirtazapine, omeprazole, sertraline, clonazepam, topiramate, fiber, and tramadol. The paper MAR printed later showed that a CMT signed off as administering all of the missed opportunities for many of these medications, and also pre-signed gabapentin before the medication was due. The CMT stated that the documentation was completed on the paper MAR after the fact and that staff should never document a medication as given before it was actually administered. The second resident had diagnoses including schizophrenia, and the July 2026 eMAR showed missed administrations for atorvastatin, furosemide, latanoprost, levothyroxine, olanzapine, Paxil, trazodone, brimonidine, Depakote, medroxyprogesterone, timolol, gabapentin, and Valium. The paper MAR received for this resident showed only one page and included signatures indicating that missed doses had been administered, while timolol, gabapentin, and Valium were pre-signed before they were due. Staff interviews confirmed that the internet outage affected documentation, that some staff used hotspots while others used paper MARs, and that the DON directed staff to sign the paper MARs later. The DON acknowledged that staff should not document medication administration before the medication is actually administered and that the residents should have had completed documentation at the time of administration.
Unauthorized Marijuana Given to Resident
Penalty
Summary
The facility failed to ensure staff provided care and services according to professional standards of quality for one resident reviewed for medication administration. Resident 4 was admitted with diagnoses including osteoarthritis, mild cognitive impairment, and anxiety disorder, and had a care plan addressing pain management, including monitoring for side effects of pain medication and offering non-pharmacological pain interventions. The resident also had physician orders for tramadol, acetaminophen, ice or heat application, and morphine sulfate oral concentrate as needed for pain. A former RN provided Resident 4 with edible marijuana that was not ordered by the resident’s physician. An LPN who was receiving orientation from the RN observed the RN cut up what appeared to be candy in the resident’s room, then heard the RN identify it as edible marijuana gummies and acknowledge that she was giving them to the resident. The LPN observed the RN place pieces of the gummies within the resident’s reach. The RN later stated she had provided edible marijuana to the resident and had not given it to other residents.
Failure to Secure and Track a Resident’s Narcotic Medication
Penalty
Summary
The facility failed to maintain professional standards of nursing practice for the storage, tracking, and reconciliation of a scheduled controlled substance for one sampled resident. The resident had been admitted with diagnoses including left femoral neck fracture, muscle wasting and atrophy, and unspecified pain, and the admission MDS reflected a BIMS score of 9, indicating moderate cognitive impairment. Review of the facility policy showed it did not specifically address new narcotic medication security after delivery from the pharmacy, and the DON stated the facility did not have a policy for checking in narcotic medications or a drug diversion policy. The resident’s Norco 7.5 mg 30-count blister pack was delivered to the facility, but it was not properly signed into the medication cart and was later found missing when the resident requested PRN pain medication and none was available. Interviews and the facility’s investigation showed an LPN received the narcotic medication and asked a KMA to assist with logging it in, the KMA placed it in the cart and told the oncoming RN that the RN would need to complete the blue and white narcotic sheets, and RN 2 failed to sign the medication into the cart as requested. The investigation also noted RN 2 had suspicious behavior, had accidentally taken home a resident’s medication on another occasion, and the missing Norco was never located.
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