Failure to Follow Ordered Medication Hold Parameters
Summary
The facility failed to ensure physician-ordered medication parameters were followed for multiple residents whose drug regimens included blood pressure medications and pain medication with specific hold parameters. The report identified 6 of 8 residents reviewed for unnecessary medications: Residents #15, #179, #6, #23, #88, and #94. The deficiency was based on medication administration records showing medications were given when the documented blood pressure or pain scores did not meet the prescriber’s ordered parameters. Resident #15 had diagnoses including sequela of cerebral infarction, major depressive disorder, and essential hypertension. The physician ordered Losartan 25 mg twice daily for HTN with instructions to hold for systolic blood pressure below 130. The MAR showed Losartan was administered multiple times in January 2026 and once in February 2026 when blood pressures were below the ordered threshold, including readings such as 116/53, 123/49, 116/64, 118/66, 127/54, 95/55, and 92/54. An LPN stated that if there was a check mark, the medication was probably administered and that the orders should be followed to hold the medication when parameters were present. Resident #179 had diagnoses including orthopedic aftercare following surgical amputation, diabetes with hyperglycemia, hypertension, hyperlipidemia, polyneuropathy, peripheral vascular disease, and anemia. The physician ordered Oxycodone-Acetaminophen 10-325 mg every 4 hours as needed for non-acute moderate pain 6-10. The MAR showed the medication was administered on several occasions when the documented pain scores were 5, 5, 5, 4, and 5. An LPN stated the pain medication was given and acknowledged the doctor’s ordered parameters should have been followed and the doctor called if the pain score was not within range. Resident #6 had diagnoses including cerebral infarction, major depressive disorder, schizoaffective disorder bipolar type, diabetes, essential hypertension, and generalized anxiety disorder. The physician ordered Enalapril Maleate 20 mg daily for HTN with instructions to hold for systolic blood pressure less than 110. The MAR documented administration on 12/28/2025 with a blood pressure of 108/50, on 1/18/2026 with a blood pressure of 101/55, and on 1/21/2026 with a blood pressure of 102/44, all signed as administered. An LPN stated the check mark on the MAR meant the medication was administered and that it was given outside the physician’s ordered parameters. Resident #23 had diagnoses including essential hypertension, chronic diastolic heart failure, and hypertensive heart disease with heart failure. The physician ordered Midodrine 10 mg three times daily for hypotension with instructions to hold for systolic blood pressure greater than 110. The MAR showed Midodrine was administered repeatedly in December 2025 and January 2026 when systolic blood pressures were above the hold parameter, including readings of 124/59, 144/82, 138/75, 122/51, 115/67, 120/56, 112/59, 120/72, 117/59, 131/73, 122/58, 113/70, 115/63, 120/78, and 121/59. An LPN stated that if there was a check mark, the medication had been given. Resident #88 had diagnoses including essential hypertension, paroxysmal atrial fibrillation, chronic combined systolic and diastolic heart failure, and type 2 diabetes mellitus. The physician ordered Sacubitril-Valsartan 24-28 mg twice daily for HTN with instructions to hold for systolic blood pressure less than 110. The MAR documented administration on multiple dates in December 2025 and January 2026 when blood pressures were below 110, including 101/61, 105/69, 103/67, 106/66, 100/73, 102/64, 106/64, 100/60, 106/60, 101/64, 102/73, 101/64, 104/57, 108/71, and 108/75. Staff stated that a check mark on the MAR meant the medication was given and that parameters were supposed to be followed. Resident #94 had diagnoses including essential hypertension and atrial flutter. The physician ordered Carvedilol 3.125 mg twice daily for HTN and Diltiazem 120 mg twice daily for atrial fibrillation, both with instructions to hold if systolic blood pressure was less than 110. The MAR showed Carvedilol and Diltiazem were administered on multiple occasions in December 2025 and January 2026 when blood pressures were below the ordered threshold, including 105/60, 102/59, 102/70, 109/68, and 100/60. The facility policy stated medications are administered in accordance with written orders of the prescriber.
Penalty
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Failure to document NPI before PRN oxycodone was given to a resident with bipolar disorder and dementia. The resident had an order for PRN oxycodone and a separate order for NPI, but MAR review showed the medication was administered nine times and the progress notes did not show NPI was used first. The UM and DON stated NPI should be attempted before PRN pain meds are given.
A resident’s midodrine was administered multiple times despite MAR-documented BPs above the prescriber’s hold parameter of SBP > 120. The RN stated a check mark means the med was given and was unsure why the resident’s midodrine was marked that way, while the DON confirmed the med should not have been administered when BP was outside parameters and that the MAR check mark indicates administration.
Failure to hold antihypertensive meds as ordered occurred when staff administered Amlodipine and Carvedilol to a resident with HTN despite BP readings below the ordered diastolic parameters. The MAR showed multiple doses were given when DBP was under 60, and the DON confirmed the meds should have been held per the physician's orders and facility policy.
A resident who was not a smoker received a nicotine patch for smoking cessation after returning from a hospital stay, even though staff confirmed she had no smoking history. The resident reported the patch made her feel sick, caused diarrhea, and left her upset and stressed. Interviews showed the charge nurse did not investigate the hospital order, the resident refused the patch on multiple days, and the pharmacist’s MRR did not note the inappropriate order.
A resident with paranoid schizophrenia, CKD, and severe cognitive impairment received Metformin for 8 days even though no DM diagnosis was supported by the record. An NP note added type 2 DM and started Metformin based on an HgbA1c that was not consistent with the resident’s prior normal HgbA1c results, and later staff found no lab evidence to support the diagnosis or order. The guardian questioned the order, and staff could not provide evidence of incident-specific education.
A resident with dementia, HTN, and edema had an order for daily amlodipine with hold parameters for low systolic BP or HR. The MAR showed the medication was given regularly without evidence that BP and HR were checked before administration, and vital signs records showed they were not being monitored daily. The DON confirmed the findings.
Failure to Document Nonpharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to provide nonpharmacological interventions before administering PRN oxycodone for Resident 16, who was admitted with diagnoses including bipolar disorder and dementia and was able to make needs known. The resident had a provider order for PRN oxycodone and a separate order to document non-pharmacological interventions such as heat, repositioning, relaxation breathing, food or fluid, massage, exercise, immobilization of a joint, or other interventions in the progress note. Review of the medication administration record for May 2026 showed the resident received PRN oxycodone on nine occasions, and review of the progress notes for that month did not show documentation that nonpharmacological interventions were used before the medication was given. During interviews, the Unit Manager stated the facility ensured PRN pain medications were necessary by providing NPI first, and the DON stated NPI should be attempted prior to giving PRN pain medications and that the resident’s lack of NPI prior to receiving PRN oxycodone did not meet expectations.
Medication Administered Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure Resident #108’s medication regimen remained free from unnecessary drugs by administering midodrine outside of the prescriber’s ordered parameters. The physician orders dated 03/13/2026 and 05/20/2026 directed midodrine 5 mg by mouth three times daily for hypotension and to hold the medication for systolic blood pressure greater than 120. Review of the May 2026 MAR showed multiple administrations of midodrine when the resident’s documented blood pressure was above the hold parameter, including readings such as 132/84, 130/81, 130/72, 140/72, 132/70, 121/61, 126/74, 122/70, 129/68, 122/75, 131/73, 136/69, 134/72, 130/70, 145/78, 145/65, 126/62, 121/66, and 124/62. During interview, Staff K, RN stated that a check mark on the MAR means a medication was administered and that if a medication is held, a number should be documented in the MAR along with a nursing note, but she was not sure what happened with the resident’s midodrine. The DON stated that the check mark means the medication was given and that nurses should not have administered midodrine if the blood pressure was outside of parameters. The facility policy required medications to be administered as prescribed in accordance with written prescriber orders.
Failure to Hold Antihypertensive Medications for Low Blood Pressure
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when the facility failed to hold a resident's antihypertensive medications as ordered based on blood pressure parameters. Resident 23 had diagnoses including hypertension, and the care plan for ineffective tissue perfusion directed staff to administer medications as ordered and monitor vital signs. The physician's orders for May 2026 directed staff to give Amlodipine 10 mg daily only if systolic blood pressure was at least 100 and diastolic blood pressure was at least 60, and to give Carvedilol 25 mg twice daily only if systolic blood pressure was at least 110 and diastolic blood pressure was at least 60. Review of the MAR showed Amlodipine was administered on multiple days when the resident's diastolic blood pressure was below 60, including readings of 54 and 59. Carvedilol was also administered on multiple occasions when the diastolic blood pressure was below 60, including readings of 54, 58, 59, 50, and 57. The DON reviewed the MAR and confirmed that Amlodipine and Carvedilol were administered on those dates when they should have been held. The facility policy stated staff should verify the correct medication, dose, route, rate, time, and resident, and obtain vital signs if necessary.
Unnecessary Nicotine Patch Given to Non-Smoker
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs when the resident received a nicotine patch despite being a non-smoker. The resident was admitted with diagnoses including long-term use of antibiotics due to infection of her knees, and her MDS BIMS score was 15, indicating good decision-making ability. The resident later reported that after returning from a hospital stay, she was given a nicotine patch without any explanation, even though she was not a smoker. The resident stated that the nicotine patch made her feel sick, caused diarrhea, and left her very unhappy and stressed. During record review and interview, the charge nurse confirmed that the resident had orders for nicotine patches for smoking cessation and had refused them on multiple days. The charge nurse also confirmed that the resident was not a smoker, had not been a smoker before going to the hospital, and that no investigation was done at the time the resident returned with a hospital order for nicotine patches. Additional interviews confirmed that the resident was not a smoker. The social services assistant verified records showing the resident was not a smoker, and the activities director stated she had no reason to complete a smoking assessment because the resident was not a smoker. The pharmacist stated that a nicotine patch given to a non-smoker can cause stomach upset, nausea, and/or diarrhea, and that a non-smoker should not receive one. The pharmacist’s medication regimen review did not reference the nicotine patch order or the resident’s non-smoking status.
Unnecessary Metformin Given Without Supported Diabetes Diagnosis
Penalty
Summary
The facility did not ensure that a resident’s drug regimen was free from unnecessary drugs when R2 received Metformin for 8 days despite having no diagnosis of diabetes. R2 was admitted with diagnoses including paranoid schizophrenia and chronic kidney disease, had a BIMS score of 7/15 indicating severe cognitive impairment, and had a legal representative for health care decisions. The care plan identified R2 as at risk for impaired cognitive function and included reviewing medications and causes of cognitive deficit, including new medications. Record review showed an NP progress note documented a diagnosis of type 2 diabetes mellitus and started Metformin ER 1000 mg daily based on an HgbA1c of 12.1%, but later nursing review found no recent HgbA1c results to support the diagnosis or order. R2’s prior HgbA1c values were 5.5 and 5.6, both within normal range. Staff documented that the NP stated the diagnosis had been dictated incorrectly, and Metformin was discontinued. The resident’s guardian was informed of the medication initiation and later questioned the diagnosis and order. Surveyor interviews also found staff could not provide evidence of education specific to the medication error incident, and facility leadership confirmed they could not provide evidence that such education had been given.
Blood Pressure Medication Given Without Required Vital Sign Monitoring
Penalty
Summary
The facility failed to ensure that parameters for Resident #49’s blood pressure medication were monitored before administration. Resident #49 was admitted with diagnoses including dementia, hypertension, and edema, and had an order dated 05/06/25 for amlodipine daily with instructions to hold the medication if systolic blood pressure was under 110 or heart rate was under 60. Review of the medication administration record showed the amlodipine was given regularly without evidence that blood pressure and heart rate were assessed before administration, and review of vital signs assessments showed the heart rate and blood pressure were not being checked daily. The Director of Nursing confirmed these findings during interview on 05/20/26 at 5:05 P.M.
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