An incomplete allopurinol order was not clarified before administration to a resident. The order directed one tablet daily but did not include the dosage, yet nursing staff administered the medication for months, including 100 mg by mouth from the blister pack. An LPN stated the dose could not be verified and should have been clarified with the physician, who said he was not contacted about the missing dosage. The DON confirmed the order should have included a dosage and should not have been administered without clarification.
Failure to clarify and obtain an order for a right arm sling: A resident returned from the hospital with a right humerus fracture and was wearing a sling, and the orthopedist recommended maintaining the sling and removing it during exercise. The record showed no physician order for the sling’s use, location, or frequency, and no documentation that the recommendation was implemented pending clarification; the ADON, LPN, and DON acknowledged the lack of physician notification and order.
Failure to Implement Physician Orders: Two residents with severe cognitive impairment had physician orders that were not carried out or documented as completed. One resident had an order to increase oral fluid intake, and another had an order for a follow-up CBC related to anemia monitoring; interviews with nursing, medical records, and corporate RN staff confirmed the orders were not implemented as ordered.
A facility failed to ensure medications were actually consumed for two residents whose MARs showed scheduled meds as administered. One resident with multiple chronic conditions and intact cognition had morning meds and prior-night Tylenol left at the bedside, and he stated staff routinely left meds for him to take later. Another resident with CHF had Lasix documented as given, but a tablet was still found in a cup on the bedside table. Staff confirmed nurses were responsible for observing residents take all meds and that medications should not be left at the bedside.
Failure to perform ordered blood glucose monitoring for two residents with diabetes. One resident was admitted with CKD, DM with hyperglycemia, dementia, and recent DKA, and had an order for BG checks before meals and at bedtime, but no BG results were documented for two scheduled checks on the admission day. Another resident with pneumonia, CHF, COPD, DM, and dementia had an order for BG monitoring twice daily, but no BG results were documented for the first two days after the order began. An LPN and the DON confirmed the missing monitoring.
Medication administration failed to meet professional standards when an LPN left morning meds at the bedside for two residents and did not observe them swallow the medications. Both residents had intact cognition but had not been assessed or approved for self-administration, and the DON confirmed the nurse should have remained with them to ensure the meds were taken.
An LPN borrowed Vistaril from one resident and gave it to another resident when the ordered medication was unavailable. The resident was cognitively intact and had an order for Vistaril 25 mg QID for rash/itching. Staff later confirmed the medication was borrowed from another resident instead of following the facility’s refill process, and the DON stated this was not acceptable.
Failure to Document and Assess Bruising: A resident with severe cognitive impairment and atrial fibrillation was receiving Eliquis and had orders for anticoagulant side-effect monitoring and weekly skin checks, but the MAR/TAR and skin assessments did not document bruising. Surveyors observed extensive bruising on the resident's hand, fingers, and neck, and the DON confirmed the bruising was not documented in the EHR.
Failure to document PRN medication administration and leave medications unattended at the bedside. An LPN gave a resident Promethazine for nausea and vomiting but did not document the MAR entry or the resident’s response, and another LPN placed oral meds in a cup on a resident’s bedside table and left without observing the resident swallow them, even though the resident had not been assessed for self-administration.
Medication administration was not handled according to professional standards when an LPN left meds at the bedside for two cognitively intact residents. One resident received melatonin without a current order, and another resident was left with multiple morning meds in cups on the bedside table after the nurse did not observe the full administration. The DON confirmed meds should not be left at the bedside and should not be given without a physician order.
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