Failure to Hold Warfarin and Complete Ordered INR Monitoring
Summary
The deficiency involves the facility’s failure to ensure a resident’s anticoagulation drug regimen was free from unnecessary drugs and was adequately monitored. The resident was admitted on warfarin for a mechanical heart valve, with physician orders for 5 mg dosing and ongoing PT/INR monitoring. Laboratory results showed critically elevated PT/INR values, including a PT of 94.9 seconds with an INR of 9.12 and later a PT of 180 seconds with an INR of 17.63. Despite these elevated results, the clinical record shows that warfarin was administered, and there is no evidence that nursing staff consistently contacted the physician for guidance prior to giving the medication when the INR was elevated. Physician orders were in place to hold warfarin pending INR results and later to adjust the dose to 2.5 mg on one day and resume 5 mg daily thereafter, with associated INR monitoring. The Medication Administration Record indicates that nurses initialed administration of 2.5 mg on the ordered day and 5 mg on subsequent days, including days when the INR was documented as 3.38 and 9.12. The record further shows that warfarin 5 mg was documented as administered during a period when the order indicated the medication was on hold. There is no documentation that the physician was notified when the INR values were elevated prior to these administrations. After the INR reached a critically high value of 17.63, the physician ordered vitamin K and daily PT/INR labs for two days; however, the lab results provide no evidence that these ordered labs were drawn on the specified days. The next PT/INR was not completed until a later date, by which time the resident had experienced a change in condition, including being nonresponsive and not eating. Progress notes from an advanced registered nurse practitioner and another practitioner describe the resident as drowsy, less responsive, and exhibiting an overall decline. The DON confirmed in interview that the ordered labs were not drawn on the specified days and that there is no evidence nurses contacted the physician before administering warfarin when the INR was elevated.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because it is required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] , resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. As of [R] , there are no residents on [R] . No additional residents were identified as negatively [R] . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A. On [R] , the Director of Nursing/Designee identified and reviewed current residents receiving [R] . The review included verification of current physician orders, review of [R] INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of review, there were no residents in the facility receiving [R] , however, all other [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification of orders. (2) (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R] , License Nursing staff will have been educated by the Director of Nursing/Designee on the components of F757, including the use of the [R] management protocol, documentation of indication and monitoring, appropriate response to laboratory results, and timely physician notification, with an emphasis on avoidance of unnecessary drugs and compliance with monitoring requirements for [R] .B. Newly hired license nursing staff will receive education by the Director of Nursing/Designee on the components of F757, including the use of the management protocol, documentation standards, critical lab value reporting and escalation processes, and physician communication expectations during orientation as part of the facility's systematic changes.(3) (4) How the corrective action(s) will be monitored to ensure the practice will not recur, ie., what quality assurance program will be put in place:A. The Director of Nursing/designee will conduct [R] monitoring audits weekly for 4 weeks, then biweekly for 4 weeks, and monthly x 1 month. Audits will review appropriate drug use, compliance with laboratory monitoring, timely physician notification, and accuracy of documentation.The findings of these quality monitoring is to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Penalty
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A resident with dementia and other comorbidities was ordered Metoprolol Tartrate 50 mg twice daily for HTN, with instructions to hold the dose if systolic BP was below a specified threshold. Review of the MAR and vital sign records showed the medication was routinely administered at scheduled times without documented BP checks around those administrations. The DON confirmed that BP was not monitored as ordered, despite facility policy requiring that medication administration parameters be noted, resulting in a deficiency related to unnecessary drug use.
Surveyors found that two residents did not receive medications in accordance with physician orders and drug administration guidelines. One resident on Metoprolol for hypertension and heart disease had the drug given nightly with blood pressure documented, but staff did not obtain or document the ordered apical pulse with hold parameters for HR <60 bpm. Another resident receiving weekly Fosamax for osteoporosis had the medication administered in the morning around the same time as breakfast service, despite orders to give it with a full glass of water on an empty stomach and drug information specifying administration at least 30 minutes before any food or other medications.
Surveyors found that multiple residents receiving PRN Ativan for anxiety had physician orders requiring non-pharmacological interventions such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, toileting, and pain management to be used and documented for monitoring. Review of MARs and nursing progress notes showed that PRN Ativan was administered on several occasions without any documentation that these non-pharmacological measures were attempted beforehand. In an interview, the IDON acknowledged that staff did not complete or document the ordered non-pharmacological interventions prior to giving Ativan and noted there was no specific policy addressing this requirement, despite the need to follow physician orders.
A resident without documented psychiatric diagnoses or anxiety symptoms was started on BuSpar and Trazodone following a psychiatric evaluation that relied on the resident’s self-reported sadness, anxiety, and sleep issues, while depression was still being ruled out. Nursing notes did not document the psychiatrist’s assessment or the new psychotropic orders on the day they were made, and there was no clear documentation that the responsible party was notified when BuSpar was initiated. The MAR showed BuSpar was entered and administered twice before being discontinued, and the responsible party later reported not understanding why the medications were started and expressed concern due to the resident’s prior adverse reactions to psychotropics. Interviews with ADONs revealed inconsistent accounts of when and how the responsible party was informed and showed that the rationale for Trazodone was not discussed, contrary to facility policy requiring immediate notification and documentation when there is a change in the resident’s status or treatment.
Surveyors found that two residents received antibiotics without adequate justification, documentation, or defined duration. One resident with multiple chronic conditions and an indwelling catheter was given Cephalexin twice daily for infection prevention over an extended period with an indefinite stop date, no supporting lab results, and no current UTI, and the prescribing specialist was unaware of the ongoing therapy. Another resident with severe cognitive impairment and total dependence for ADLs was started on Cefdinir for a UTI by an NP, but the record contained no abnormal urinary signs, symptoms, or test results, and no urine culture was obtained before treatment. These practices did not follow the facility’s antibiotic stewardship policy requiring clear indications, start/stop dates, and appropriate clinical information for antibiotic use.
A resident with a history of cerebral infarction and asthma was ordered Metoprolol Tartrate for HTN with instructions to hold the dose if SBP was below 110 or HR below 60, and to obtain and record vital signs to guide administration. Over an extended period, no SBP or HR values were documented on the MAR, and staff later confirmed that several doses should have been held but were not. This practice was inconsistent with the facility’s own medication administration policy requiring vital signs to be obtained and medications held when ordered parameters are not met, resulting in the resident receiving medication without adherence to prescribed hold parameters.
Failure to Monitor BP Parameters Before Administering Antihypertensive Medication
Penalty
Summary
Surveyors identified that a resident with dementia, dysphagia, and peripheral vascular disease, who was rarely or never understood, did not have blood pressure monitored as required in relation to an ordered antihypertensive medication. The physician’s order dated 12/01/25 directed that Metoprolol Tartrate 50 mg by mouth be given twice daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 110 mmHg. Review of the Medication Administration Records for March 2026 and early April 2026 showed the medication was administered at 9:00 A.M. and 9:00 P.M., but there was no documentation that blood pressure was checked around those administration times. Review of the resident’s vital sign records likewise showed no evidence of blood pressure monitoring at or near the times the medication was given. In an interview, the DON confirmed that the resident’s blood pressure was not being monitored as ordered, despite facility policy stating that any parameters around drug administration should be noted when administering medications. This deficiency was cited as noncompliance related to ensuring each resident’s drug regimen is free from unnecessary drugs, based on the failure to follow ordered parameters for blood pressure monitoring before administering Metoprolol Tartrate.
Failure to Follow Medication Parameters and Fasting Requirements for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ drug regimens were free from unnecessary drugs by not following specific physician orders and administration parameters. For one resident with hypertensive heart disease with heart failure, atrial fibrillation, and hypertension, the physician ordered Metoprolol Succinate ER 25 mg to be given nightly at bedtime with parameters to hold the medication if the systolic blood pressure was less than 100 mmHg or the heart rate was less than 60 bpm. Review of the MARs for March and April showed the medication was administered at 9:00 P.M. with blood pressures documented prior to administration, but there was no documentation that an apical pulse was checked before giving the medication, despite the order including heart rate parameters. Further review of the resident’s EMR, including the vital signs tab, revealed no evidence that an apical pulse was obtained and recorded at times corresponding to the administration of Metoprolol. This lack of documentation was confirmed by the DON, who was unable to locate any record of apical pulse checks prior to the nightly doses. The DON acknowledged that the resident’s heart rate should have been checked because Metoprolol is known to slow the heart rate. The deficiency also includes the facility’s failure to administer an osteoporosis medication in accordance with physician orders and recommended administration guidelines. Another resident, diagnosed with age-related osteoporosis, had an order for alendronate sodium (Fosamax) 70 mg once weekly on Fridays, to be given with a full glass of water and on an empty stomach. The MAR and a 30-day medication administration audit showed that the Fosamax was administered between 8:25 A.M. and 8:53 A.M., while breakfast on that hall was served at 8:30 A.M. in the dining room or at 8:50 A.M. in the resident’s room. An LPN confirmed that the resident typically ate breakfast at those times and acknowledged that, based on the administration times, the medication was not being given on an empty stomach, which would result in poor absorption according to the drug information cited from Medscape.
Plan Of Correction
1. Resident #12 had their order for Fosamax clarified with the physician on 4/8/26 by a licensed nurse to administer the medication on an empty stomach. Resident #12 was assessed by the Director of Nursing on 5/7/26 with no ill effects noted. Resident's Fosamax was discontinued by the physician on 4/30/26. Resident #100 had their order for Metoprolol updated to include monitoring of their pulse on 4/14/26 by the Director of Nursing. Resident #100 was assessed by the Director of Nursing on 5/7/26 with no ill effects noted. 2. Like Residents are identified as residents who utilize bisphosphonate medications for the treatment of osteoporosis. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents who utilize medication for osteoporosis receive them on an empty stomach and/or according to physician orders. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize betablocker medications with specific orders to monitor their pulse for the treatment of hypertension. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents who utilize beta blocker medication for hypertension have their pulse monitored when the physician indicates specific parameters within the order. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Physicians Order Policy to ensure orders include and are transcribed with the information that is necessary and accurate to carry out the order correctly. This education will be completed on or before 5/13/26. 4. Utilizing the Medication Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents who utilize medication for osteoporosis receive them on an empty stomach and/or according to physician orders and to ensure residents who utilize beta blocker medication for hypertension have their pulse monitored when the physician indicates specific parameters within the order. Discrepancies noted during the audits will be corrected with physician orders clarified. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Implement Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
Surveyors identified a deficiency related to the requirement that each resident’s drug regimen be free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications without prior non-pharmacological interventions. For one resident with hip fracture, dementia, anxiety, and bipolar disorder, the record showed a physician’s order for non-pharmacological interventions (such as relaxation, quiet room, massage, food, fluids, music, repositioning, activity involvement, pain medication, and other measures documented in progress notes) to be used for monitoring, and a separate order for PRN Ativan 0.5 mg for anxiety. The MAR documented multiple administrations of PRN Ativan over several days, but review of the MAR and nursing progress notes showed no documentation that non-pharmacological interventions were attempted prior to giving the medication on any of those occasions. Another resident with Alzheimer’s disease and anxiety had physician orders for non-pharmacological interventions similar to those above, as well as an order for PRN Ativan 0.25 mg for anxiety. The MAR showed several PRN Ativan administrations over a three-day period, but the MAR and nursing progress notes lacked documentation of non-pharmacological interventions before the medication was given. A third resident with dementia, hypertension, and incontinence had an order for non-pharmacological interventions and subsequent orders for scheduled and PRN Ativan for anxiety. Review of this resident’s MAR and nursing notes showed PRN Ativan was administered without any documented alternate non-pharmacological interventions beforehand. In an interview, the Interim DON confirmed staff failed to complete or document non-pharmacological interventions prior to administering Ativan and stated there was no specific facility policy requiring such interventions before psychotropic medications, though physician orders were to be followed.
Failure to Ensure Appropriate Indication and Notification for New Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medications by not establishing and documenting appropriate indications for new psychotropic drugs. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur had no documented history of generalized anxiety disorder, depression, or other psychiatric conditions in the medical record. Review of progress notes over several days showed no signs or symptoms of anxiety and no documentation of referral to psychiatric services. During an admission psychiatric evaluation, the consulting psychiatrist documented the resident’s self-reported sadness, depression, poor sleep, anxiety, and restlessness, diagnosed generalized anxiety disorder, ordered BuSpar 10 mg orally twice daily for anxiety, and Trazodone 25 mg orally every evening while depression was still being ruled out and not listed as a confirmed diagnosis. The nursing documentation did not reflect the psychiatrist’s assessment or the new orders for BuSpar and Trazodone on the date they were made, and there was no documentation of notification of the resident’s responsible party regarding the initiation of BuSpar. The MAR showed the BuSpar order was entered the day after the psychiatric evaluation, and the resident received two doses before discontinuation. The responsible party later reported that the medications were started for an unknown reason, stated the resident had prior adverse reactions to psychotropic medications, and did not want medications that cross the blood-brain barrier. Interviews with the ADONs revealed conflicting accounts about whether and when the responsible party was notified of the new orders, with one ADON stating she did not notify the family by phone and that all communication was in person, and acknowledging that nothing was discussed regarding the rationale for Trazodone. The facility’s policy required immediate notification of the resident and authorized representative, consultation with the practitioner, and documentation in the medical record when there is a change in mental, physical, or psychosocial status, which was not consistently followed in this case.
Unjustified and Poorly Documented Antibiotic Use for Two Residents
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary antibiotics, resulting in antibiotic use without adequate indications, monitoring, or defined duration. One resident with hemiplegia, type 2 diabetes, bladder dysfunction, hypertension, and an indwelling urinary catheter had a physician order for oral Cephalexin 500 mg twice daily “for prevention of infection” with an indefinite end date. A pharmacy note requested clarification of a stop date, but the medication was administered continuously for several months. The medical record contained no documentation justifying extended use of Cephalexin, no related laboratory results, and the resident did not currently have a UTI. The Infection Preventionist confirmed the antibiotic had been ordered and administered for an extended period, had not appeared on the ordered antibiotic list, and that the urology office had not ordered or been aware of the ongoing Cephalexin use, with no documented justification for its continual use. Another resident with cerebral palsy, profound intellectual disabilities, seizures, hypertension, dysphagia, severe cognitive impairment, and total dependence for ADLs received Cefdinir suspension ordered by a nurse practitioner for a UTI. Nursing documentation noted the NP visit and the new Cefdinir order, and the medication was administered as ordered. However, the medical record lacked documentation of abnormal urinary signs or symptoms or any test results to support the antibiotic use. The Infection Preventionist confirmed there was no documentation to support Cefdinir as treatment for a UTI and that a urine culture was not obtained prior to starting the antibiotic. These practices were inconsistent with the facility’s “Antibiotic Stewardship” policy, which requires complete antibiotic orders including indication and duration, and specific clinical information to be communicated when a nurse contacts a prescriber about a suspected infection.
Plan Of Correction
F757 Unnecessary drugs The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 39 has been reviewed by physician on March 14, 2026, for ongoing use of antibiotic with justification of use to prevent UTI. Resident # 40 as of Feb 22, 2026, is no longer receiving this antibiotic. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents in the facility who have antibiotics without stop dates being used as a prophylactic treatment would be like residents. The sweep completed by the infection preventionist on 3/25/26 of current residents did not identify such residents. Any residents receiving antibiotics require documentation of the reason for antibiotic use. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Inservice for nurse managers and licensed nurses to follow the antibiotic stewardship protocol a. Drug name; b. Dose; c. Frequency of administration; d. Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy; route of administration; and f. Indications for use. The policy also stated that when the nurse calls a physician/prescriber to communicate a suspected infection, he/she would have the following info: when symptoms first observed, the resident's hydration status, current medication list, and the infection type. Inservice per DON/designee and completed by 4-9-2026. Residents with antibiotics ordered must have reason for the antibiotic identified. How the corrective action will be monitored to ensure the deficient practice will not recur. Daily audit of orders for antibiotics without stop dates began 3/25/26 by infection preventionist all antibiotic orders and will be audited weekly x 4 weeks by DON/designee to ensure all antibiotics have automatic stop dates Results are submitted to QAPI committee weekly. Concerns identified will be corrected at the time of audit, and education of nurses will be done to remind them that we need to have a stop date for any antibiotics ordered.
Failure to Follow Ordered Vital Sign Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered parameters for administration of Metoprolol Tartrate. The resident, admitted with diagnoses including cerebral infarction, unspecified and unspecified asthma, uncomplicated, had a physician order dated 01/30/26 for Metoprolol Tartrate 25 mg, 1.5 tablets by mouth twice daily for HTN, with instructions to hold the medication if systolic blood pressure (SBP) was below 110 or heart rate (HR) was below 60. Review of the medication administration record showed no documented SBP or HR from 01/30/26 through 02/26/26, despite the order requiring these parameters to determine whether the medication should be given or held. Pharmacy reiterated the same hold parameters on 02/26/26, yet vital signs were still not documented for the earlier period, and staff interviews confirmed that the medication should have been held for specific doses on 03/10/26 and 03/11/26 but was not. Review of the facility’s Medication Administration Policy dated 08/22/22 showed that staff were required to obtain and record vital signs when applicable or per physician orders and to hold medications when vital signs fell outside prescribed parameters, which was not followed in this case. This deficiency was identified for one resident out of five reviewed for unnecessary medications, with a facility census of 92, and was investigated under Complaint Number 2696141.
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