F0726

G

Widespread Nursing Competency Failures in Emergency Response, Glucometer Use, Med Pass, and GT Administration

Laguna Hills, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that licensed nurses possessed and demonstrated the competencies required to provide safe and effective care, as evidenced by multiple incidents involving five nurses. For one resident with aspiration pneumonia, respiratory failure, COPD, CHF, chronic atelectasis, and dementia, the care plan required monitoring for respiratory distress and reporting changes to the physician. On the night in question, this resident’s vital signs changed significantly: blood pressure rose to 174/102, respiratory rate increased to 22, oxygen saturation dropped to 83–85% on 2 L O2 via nasal cannula, and temperature fell to 95°F. LVN 8 documented thick white phlegm in the resident’s mouth, performed oral suctioning with 200 ml of phlegm obtained, notified the physician and DON, and left messages for emergency contacts, but did not call 911. LVN 8 stated they believed that because the resident was DNR, 911 should not be contacted and that they were waiting for direction from the MD, RN, and family, despite acknowledging the resident was in distress and still breathing with a heartbeat.

Further review of the same resident’s record showed that earlier vital signs that night were within normal limits, and that after the change in condition and suctioning, there was no documented reassessment of vital signs. The MAR showed the resident received levothyroxine and ipratropium bromide inhalation, but there was no documentation of vital sign reassessment after the inhalation treatment. Later that morning, RN 1 assessed the resident and found blood pressure 78/58, respiratory rate 12, oxygen saturation 73%, and disorientation with inability to follow commands. Oxygen was escalated to a non-rebreather at 15 L/min and another nurse was instructed to call 911, and the resident was transferred to the hospital. The DON later stated that LVN 8 focused primarily on breathing and failed to address the abnormal vital signs, and that LVN 8 had not attended the facility’s in-service on LVN scope for respiratory devices.

Additional deficiencies in competency were identified in glucometer calibration, medication administration, and GT medication technique. When asked to calibrate a glucometer, LVN 2 stated she had only been shown once, believed NOC shift nurses did it, and was unsure when calibration was needed, stating she would ask an RN supervisor. The glucometer quality control record showed mismatched lot numbers and missing open dates on strips, and control solutions labeled with open dates, while RN 1 performed a control test without entering control mode and stated she relied on box expiration dates rather than the 90-day post-opening limit. Both LVN 2 and RN 1 had competency documents indicating they met glucometer calibration skills. Another resident reported that an LVN repeatedly gave her the wrong medications; on one occasion, RN 2 verified that the resident had been given calcium with vitamin D instead of the ordered calcium alone, and RN 2 told the LVN to follow the physician’s order. In a separate observation, LVN 5 administered medications via GT without flushing the tube with 50 ml water before and after, did not flush between medications, and did not wear appropriate PPE for a resident on EBP, despite documentation that GT and infection control competencies had been signed off. These findings collectively showed that multiple nurses lacked the specific competencies and standard-of-practice skills required for safe care.