Failure to Follow Ophthalmic Administration Guidelines and PRN Antihypertensive Orders
Summary
The deficiency involves failures in pharmacy services and medication administration, including not following manufacturer instructions for ophthalmic medications and not administering an ordered PRN antihypertensive medication when clinical parameters were met. For one resident with diagnoses including unspecified dementia, essential hypertension, chronic kidney disease, mixed hyperlipidemia, and glaucoma, physician orders directed the use of brimonidine tartrate ophthalmic solution and dorzolamide-timolol ophthalmic solution, each to be instilled as one drop in both eyes twice daily. Manufacturer instructions for both ophthalmic products specified that when more than one topical ophthalmic drug is used, they should be administered at least five minutes apart. An LPN reported she did not know she was supposed to wait five minutes between eye drops, stated she does not wait, and that no one who trained her waited between eye drop applications. Surveyor observation confirmed that the LPN administered the two different eye drop solutions consecutively without waiting five minutes, and the LPN verified she did not wait between administrations. The deficiency also includes failure to administer a PRN antihypertensive medication as ordered for another resident. This resident had a history including pelvic fracture, chronic pain, PTSD, depression, epilepsy, hypertension, and a care plan focus for cerebrovascular accident related to hypertension, with interventions to monitor vital signs, notify the physician of significant abnormalities, and administer medications as ordered. A physician order directed clonidine 0.1 mg by mouth every eight hours as needed for systolic blood pressure (SBP) greater than 170. Review of the MAR showed multiple dates on which the resident’s SBP exceeded 170 (including readings of 219, 206, 183, 172, and 175), with no documentation that the PRN clonidine was administered on those dates. Further review of the resident’s progress notes from December through February revealed no documentation of administration of the ordered PRN clonidine during the periods when elevated SBP values were recorded. The resident reported concern that his blood pressure was often too high, stated that staff were monitoring his blood pressure, and reported that his cardiologist indicated no one from the facility was reporting blood pressure abnormalities. The resident also stated he could not recall receiving medications for his high blood pressure. The DON confirmed there was no documentation in the medical record of the resident receiving the PRN blood pressure medication on the dates when SBP readings were above the ordered threshold and that there were no explanatory notes corresponding to a MAR notation to “see notes.”
Plan Of Correction
F755 Pharmacy Srvcs/Procedures/Pharmacist/Records The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 22 is receiving ophthalmic drops per order with a 5-minute wait time between drops. An assessment of resident #22 was completed on 4-9-26 by the infection preventionist with no negative effects. The order was written to remind the nurses to wait 5 min between medication administration. the order was rewritten on 3/31/26 by unit manager. Resident #24 was audited on 3-31-26 by the DON and continues to receive clonidine as prescribed related to BP parameters. Resident #24 was assessed for negative effects on 4-9-26 by the infection preventionist, and none were identified How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All the residents in the facility that have eye gtt orders, there are 3 and have bp with parameters, there are 3, have the potential for this practice. A sweep of all residents with eye gtts was done 3/29/26 by nurse manager and a sweep of BP with established parameters completed 3/29/26 by the DON. These residents are in compliance with med pass. The eye gtt orders have been reviewed and written to include proper sequence of administration by MDS and ADON . Residents who have established medication parameters for blood pressure medication could also be affected by this practice but have been educated and are currently being audited for compliance What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-service all nurses in eye gtt sequencing and leave the insert with the medication to review. Additionally, nurses were in- serviced to monitor the MAR for identified parameters and follow the guidance and document. This in-service was completed 4-9-2026 How the corrective action will be monitored to ensure the deficient practice will not recur. On 3/29/26 DON/designee are auditing all residents with eye gtts 3X a week X 4 weeks for observation of medication administration with 5 min between multiple eye gtts. All of the residents with BP parameters are being audited by observation of administration and MAR 3x a week by the DON for medicating residents according to BP parameters all to ensure administration of residents with multiple eye drops will be administered at least five minutes between medicated eye drops and medication was administered according to BP parameters) Results are presented to QAPI committee weekly. If the audit reveals concerns, the nursing will be reeducated post audit.
Penalty
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The facility failed to ensure accurate pharmaceutical services for two residents and related medication storage and recordkeeping. An LPN administered a resident’s insulin glargine pen without priming it first, and a controlled medication log for another resident’s hydrocodone-acetaminophen did not match the blister pack count. In addition, a controlled substance reconciliation log for a medication aide cart had been signed before shift change, and an expired IV tubing supply was found in the LTC medication room.
Medication Error Not Investigated or Documented: The facility failed to investigate, document, and address a reported Zepbound medication error for a resident with moderate cognitive impairment and multiple diagnoses. The event report noted a wrong dose, but the record contained no clear explanation of what occurred, no documented root cause investigation, and no documented actions taken; the DON and RN both stated the process was incomplete, and the consultant pharmacist noted the expected documentation and follow-up for medication errors.
Controlled medications were not properly tracked because the narcotic accountability sheets in one medication cart had multiple entries without the required signatures from two nurses. During the audit, RN #1 and the DON both confirmed that two nurses should have signed the narcotic count sheets.
Controlled substance records were not properly maintained for the Hall A and Hall B medication carts because shift-change narcotic count signatures were missing on multiple occasions. LVNs stated that two nurses were not verifying the count by signing the book, and the DON, ADM, and CCN confirmed that missing signatures meant there was no proof the count was completed and accurate. The facility policy required a physical inventory of controlled meds at each shift change by two licensed nurses or an allowed nurse and med aide.
Incorrect Zyprexa Dose Remained Active on MAR: A resident with psychotic disorder and hallucinations had a Zyprexa dose reduced per MD order, but the prior 10 mg order was not discontinued and both the 5 mg and 10 mg doses remained active on the MAR. The MAR showed both doses were administered daily until clarification was entered, and the LVN stated he entered the new order but thought the old order had been discontinued.
A resident with ESRD, DM2, depression, anxiety, bipolar disorder, and parkinsonism did not receive ordered Renvela for an extended period despite an active EMAR order. Review showed repeated hold periods and no doses administered across multiple months, while the dialysis RD said the medication was used for elevated phosphorus and had been filled previously. Staff interviews showed confusion about whether dialysis or the facility pharmacy should refill the medication, and the DON confirmed the medication was not readily available even though it should have been.
Pharmaceutical Services and Controlled Substance Recordkeeping Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs and to ensure drug records were in order for two residents, one medication cart, and one medication room. Resident #8 had diagnoses including heart failure, high blood pressure, high cholesterol, and type 2 diabetes mellitus, and his MDS documented severe cognitive impairment and insulin use. During a medication pass observation, an LVN administered 15 units of Insulin Glargine pen without priming the pen first. The LVN stated priming was important to ensure the pen was working properly and that failure to prime could affect the dose received. Resident #20 had diagnoses including asthma, depression, high cholesterol, high blood pressure, and sciatica, and her MDS documented severe cognitive impairment and active sciatica. During observation of the nurse cart, the controlled medication log for Hydrocodone-Acetaminophen 7.5-325 mg did not match the blister pack count: the log showed 6 tablets should have been available, but the pack contained 5 tablets. The LVN stated the tablet should be logged out immediately after administration. The facility also observed that the controlled medication reconciliation log for the 500 hall medication aide cart had been signed in advance of the next shift change, and the medication aide stated it should not be signed early because the cart could be taken away and something could go missing. During observation of the LTC unit medication room, an expired IV tubing supply was found on the shelves with medication equipment and supplies. The LVN stated expired items should not be in the storage room, and the DON and Administrator both stated expired supplies should not be in the medication rooms. The facility policy for insulin pen use required a safety test before each injection, and the controlled medications policy required immediate documentation after administration and a physical inventory at each shift change.
Medication Error Not Investigated or Documented
Penalty
Summary
The facility failed to ensure a reported medication error involving Zepbound for a resident with moderate cognitive impairment and diagnoses including morbid obesity, cerebral palsy, and obstructive sleep apnea was investigated, documented, and addressed in accordance with facility policy. The resident’s event report identified a wrong dose on 4/22/26, but the report did not identify any investigation into the event or any actions taken to prevent further events, and the medical record contained no further information about the incident. During interviews, the DON stated there was a lapse in the process and that an investigation was not completed. The DON reported staff explained the medication did not come from the pharmacy and that the resident did not receive the dose, although the event report stated wrong dose. RN-A also stated there was no documentation explaining what occurred or what actions were taken. The consultant pharmacist stated staff were expected to complete a thorough root cause investigation and analysis, with follow-up and detailed documentation for any medication error, including resident assessment, physician notification when indicated, monitoring for adverse effects, and measures to prevent recurrence. The facility policy stated that when a medication error occurs, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation, or treatment is indicated, and that medication errors are tracked and trended for quality improvement purposes.
Incomplete Narcotic Count Documentation
Penalty
Summary
Controlled medications were not tracked and kept secure from potential theft and/or diversion because the facility failed to ensure the narcotic accountability sheets were properly signed by licensed nurses. During a medication cart audit, multiple dates were found on the narcotic accountability sheets without a documented on-coming or off-going licensed nurse signature, including several entries in late April, May, and early June. RN #1 stated that two nurses should have signed the narcotic accountability sheet and had not, and the DON also stated that two nurses should have signed off on the narcotic count sheets.
Missing Controlled Substance Count Signatures on Medication Carts
Penalty
Summary
The facility failed to determine that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for the Hall A and Hall B medication carts. During record review, the narcotic books for both carts were found to have missing signatures documenting shift-to-shift controlled substance counts. On the Hall A medication cart, signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/2026, 1/30/2026, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026. On the Hall B medication cart, signatures were missing on 5/3/2026 and 5/30/2026. During interviews, LVN G and LVN F stated that two nurses were not verifying the narcotic count by signing the book and that, if the count was off, there would be no way to know who to contact or verify that two nurses had counted the medications. The DON stated that when the narcotic book lacks signatures, the count could be incorrect and directly affect the medications the resident receives. The ADM stated missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for residents. The CCN stated that without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate. The facility policy required a physical inventory of controlled medications at each shift change by two licensed nurses or an allowed nurse and medication aide, documented on an audit record or accountability record.
Incorrect Zyprexa Dose Remained Active on MAR
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #32 when the facility failed to discontinue an old Zyprexa 10 mg order after the dose was changed to 5 mg in the evening. Resident #32 was admitted with a diagnosis of psychotic disorder with hallucinations and was documented as rarely/never understood with severely impaired cognition. The resident’s care plan addressed psychotropic medication use and gradual dose reduction considerations, and a pharmacy recommendation was made to decrease Zyprexa from 10 mg to 5 mg in the evening, which was signed by the physician on 5/22/2026. The active order summary showed both Zyprexa 5 mg and Zyprexa 10 mg as active, and the MAR showed both doses were administered daily from 5/22/2026 until a clarification order was entered on 6/3/2026. During interview, LVN A stated he received the dose reduction order, notified the hospice provider, entered the new 5 mg order, and thought he had discontinued the 10 mg order, but did not know why it remained active. The DON stated the charge nurse was responsible for entering new orders into the MAR and later obtained clarification from hospice regarding the medication dose.
Failure to Provide Ordered Phosphate Binder
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administration of medications for Resident #59, who was admitted with ESRD, type 2 diabetes mellitus with unspecified complications, depression, anxiety, bipolar disorder, and parkinsonism. The resident’s annual MDS showed a BIMS score of 15, indicating intact cognition. Review of the EMAR showed an order for Sevelamer Carbonate (Renvela) 800 mg, 1 tablet by mouth before meals for disorders of phosphorus metabolism, with a start date of 04/17/2026, but the resident did not receive the medication from 04/18/2026 through 04/30/2026. Further review of the May 2026 EMAR showed the same Renvela order with multiple hold periods, and the resident did not receive any doses during that month. Review of the June 2026 EMAR showed the medication remained on hold and had not been administered from 06/01/2026 through the time of review. The dialysis RD stated the resident was on a fluid restriction and was prescribed Sevelamer Carbonate because of elevated phosphorus, that dialysis and the facility communicated through forms and faxed orders, and that the medication had been filled last on 03/27/2026 and 04/20/2026. Staff interviews revealed the facility believed dialysis normally refilled the medication, but the pharmacy said it could fill it if needed. The DON stated she did not know the resident had gone without the medication and confirmed the facility did not have it readily available even though it should have.
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