Failure to Administer Ordered Narcotic and Improper Delegation of Tube Feeding Management
Penalty
Summary
The facility failed to ensure that one resident received ordered narcotic pain medication as documented, and that another resident’s tube feeding (TF) was managed only by qualified staff, in accordance with professional standards and facility policy. For one resident with dementia, a right femur head fracture, and anxiety disorder, the MAR showed that a schedule II narcotic (oxycodone-acetaminophen 5-325 mg) was documented as administered six times over three consecutive days by the same RN. Facility pharmacy policy required medications to be administered as prescribed, documented immediately after administration on the MAR, and the MAR reviewed at the end of each pass to ensure doses were given and recorded. However, a urine opiate screen performed shortly after these documented administrations was negative for opiates, and facility documentation concluded that the resident had no oxycodone in her system despite the RN’s MAR entries indicating administration. The lab technician confirmed the test was sensitive for synthetic opiates, including oxycodone, and stated that if the medication had been given as documented, the test would have been positive. The Medical Director, when informed of the negative drug screen, concluded the resident had not received the narcotic medication as ordered. The facility also failed to ensure that TF management for another resident was performed only by licensed nurses, consistent with standards of practice and regulatory requirements. The facility could not produce a policy related to staff responsible for TF management despite multiple requests. Job descriptions for RNs and LPNs required integration of current standards of practice and applicable regulations into resident care, and state regulations specified that delegation of nursing tasks must fall within sound nursing judgment. The resident involved had a gastrostomy, dysphagia, abnormal weight loss, and a history of traumatic brain compression with bilateral craniotomy and revision, and was assessed as unable to complete a BIMS interview. A CNA reported that this resident was mostly in bed, that she turned the resident every two hours, and that she paused the TF pump when getting the resident up and down. One LPN stated she knew CNAs paused the TF pump but was unsure if this was within their scope of practice, while another LPN stated pausing TF was not within CNA scope. The unit manager reported that licensed nurses were responsible for managing the TF pump and that no caregivers other than nurses were authorized to touch the pump; CNAs were expected to get a nurse if the pump needed to be paused for repositioning. The DON stated that licensed nurses were responsible for controlling the TF pump, that pausing and restarting the pump was outside CNA scope, and that CNAs should notify a nurse if repositioning was needed. The Administrator stated her expectation that CNAs act within their scope of practice.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.