Failure to Document Resident-CNA Altercation: A resident with dementia, psychosis, and a history of aggression was involved in a physical altercation with a CNA during the overnight shift. Staff witnessed the resident and CNA on the floor, and the resident later stated the CNA threw him down after he did not obey her. However, the nurse on duty did not complete an incident report or document the event, and there was no nursing progress note or charted assessment in the resident’s record.
A resident with Parkinson’s disease, dementia, and multiple other diagnoses experienced a significant change in condition with lethargy, shaking, confusion, and elevated BP, leading to hospital transfer for sepsis. An LPN contacted the NP, arranged ER transfer, and notified the family, but did not document the change in the resident’s chart at the time; the note was entered later as a late entry.
A resident with multiple diagnoses, including a cancerous mass on the right hip and impaired mobility, was found on the floor after attempting to get out of bed unassisted. The RN documented the fall more than 12 hours later and stated he should have charted it sooner; he also said he gave Tramadol but did not enter it in PCC, and the MAR did not show the dose as administered at the time of the fall. The resident later complained of pain, was evaluated by the NP, and was transferred to the hospital with a right hip fracture.
Improper Administration of Subcutaneous Epoetin Alfa Injection: An LPN administered Epoetin Alfa to a resident with CKD-related anemia at an approximately 15-degree angle into the abdomen, rather than following accepted SQ technique. The LPN was unsure of the correct angle, while the DON stated SQ injections should be given at a 90-degree angle with a skin pinch and the MD affirmed the medication is intended for SQ use. The facility’s SQ medication procedure directed a 45-degree angle, which the report stated did not meet current standards of practice.
A resident with diabetes and other chronic conditions refused Jardiance because it made him sick, but an RN documented the medication as given on the MAR and did not notify the physician at the time. The resident said staff kept giving the medication despite his refusal, while later interviews showed an LPN had reported the refusal to the DON and the attending MD had heard about it and told staff to hold the medication. The facility’s medication pass policy required signing the MAR after administration, and staff acknowledged the refusal should have been documented as refused.
A resident was given another resident’s Suboxone film after an RN entered a shared room and identified the wrong resident by calling out the bed number. The resident later reported feeling high, and the chart documented altered mental status and accidental ingestion of an unknown medication; he was observed weak, leaning over a bedside table, and unable to sit upright or eat independently before being sent to the ED for evaluation.
A RN gave a CNA a cup with physician-ordered pain medication to pass to a resident instead of administering it herself. The CNA said she believed the pills were Tylenol and delivered them because the RN was busy with another resident and on the phone with the pharmacy. The RN also admitted to previously giving a CNA another resident’s pain medication to administer.
Medication Administration Errors: An LPN administered Tylenol to a resident without a physician order, and an RN was observed measuring polyethylene glycol powder for another resident using a medicine cup marked by hand rather than the provided cap. The DON stated staff are expected to follow the five rights of medication administration and ensure medications are given according to physician orders.
The facility failed to ensure medications were administered and documented according to professional standards and facility policy. For multiple residents, audit reports showed that numerous scheduled morning medications were documented as given several hours after their scheduled times, while the RN responsible stated that medications were likely given on time but signed out later, contrary to the requirement to document immediately after administration. In a separate case, a newly admitted resident with COPD, anxiety, and other conditions did not receive ordered medications, including anxiolytics and respiratory treatments, during the entire first day after admission, despite the medication list and prescriptions being provided at admission and emergency stock containing some of the ordered drugs. Admission paperwork was delayed in reaching nursing staff, the MAR showed no administration entries for several ordered medications that day, and the facility could not produce a policy for ordering medications for new admissions.
The facility failed to follow professional standards by not completing ordered wound cultures for a resident with infected pressure ulcers and by not documenting ordered weekly skin assessments for five residents with complex medical conditions. An infectious disease NP ordered repeat wound cultures after a positive culture, but two orders were not carried out and one was not completed due to the resident being in the hospital, with the DON confirming there were no results and no explanation from the nurses who received the orders. For five other residents, active physician orders required weekly showers with skin assessments, documentation of completion or refusal, and recording of any new skin issues on a nursing skin assessment form, yet review of shower sheets over several months showed no skin assessment documentation and none was found elsewhere in the records. Staff interviews revealed that while CNAs were expected to alert nurses for skin checks and nurses were expected to perform head-to-toe assessments and document them, in practice nurses only initialed the MAR, contrary to the facility’s order-processing policy and RN/LPN documentation responsibilities.
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