Facility staff failed to administer medications in accordance with nursing practice standards for a resident with severe cognitive impairment and likely frontotemporal dementia. The resident was observed in bed holding a medication cup with pills still inside and additional pills on the chest, and the MAR showed the pills were scheduled 9 AM meds including Lasix, potassium, carvedilol, duloxetine, and buspirone. The DON confirmed the nurse should have stayed with the resident and observed the medications being taken, and should not have left any medication at the bedside.
An LPN failed to document narcotic administration accurately on the MAR and wrote illegibly on the narcotic inventory sheet for a resident receiving PRN Hydromorphone for pain. Surveyors found multiple narcotic card entries that did not clearly show the time or amount removed, illegible signatures, missing Master Signature Sheets on medication carts, and one instance where 2 tablets were given when the order called for 1 tablet based on the resident’s pain score.
Inaccurate Documentation of Hearing Aid Care: Staff failed to accurately document a resident’s hearing aid care despite an order to place the aids in the resident’s ears each morning and store them in the med cart each evening. The resident, who was cognitively intact, reported the hearing aid was missing after it had been placed in a cup on the med cart, and the MAR still showed repeated entries indicating the aids were provided and secured even after they were gone.
A resident was observed receiving oxygen while in no distress, but record review showed there was no current physician order for the oxygen. The care plan directed oxygen therapy as ordered by the physician, and the LNM confirmed the resident had been on oxygen since admission without an order. Facility policy stated oxygen is to be administered under a physician order except in an emergency.
A facility failed to obtain and implement physician orders that matched residents’ care plans and assessed needs. Two residents with significant ROM limitations and dependence for bed mobility had care plans directing turning and repositioning every 2 hours, but the corresponding physician orders were missing, and one resident’s documentation system no longer reflected the intervention. In addition, a resident with a chronic suprapubic catheter had catheter care orders, but the orders did not include the clinical indication for the catheter.
A resident’s newly admitted medication orders were not entered as STAT, and several scheduled meds were not available at the time they were due. The resident complained of pain and was told by an LPN that the pain med was unavailable until the next shift; another nurse later contacted pharmacy and obtained the medication for administration. The DON stated the expectation was to enter newly admitted residents’ medication orders as STAT so pharmacy could deliver them within four hours.
False documentation was identified when an LPN signed off that a resident’s low air loss alternating pressure mattress had been checked even though she later stated she had not done so. The resident’s mattress was observed set at 180 lbs with static on, despite an order to set it to the resident’s weight and keep static off unless providing care.
A resident with dehydration and low blood pressure did not receive ordered IV fluids until the next day, and the unit crash cart was missing IV supplies needed to start the infusion. In a separate event, an ADON performed wound care for a resident with a venous/arterial ulcer but used an abdominal pad instead of the ordered border gauze. Interviews showed staff could not locate the IV starter kit when needed, and the ADON acknowledged not reading the wound order personally.
A resident receiving tube feeding was found with the formula bottle empty at the bedside and no label showing the date, time, or infusion rate. Pump history showed the resident had received far less than the ordered amount, and the physician order did not include specific start or stop times. An LPN said the pump was already off at the start of the shift and needed to review the order to know when to run the feeding, while the DON confirmed the feeding was not labeled correctly and the order was incomplete.
A resident’s scheduled morning meds were delayed until late afternoon, and two scheduled Tylenol 650 mg doses were documented as given within three minutes of each other. The MAR showed the resident received 1,300 mg of acetaminophen as a single administration, and the DON confirmed the doses were given concurrently and exceeded the safe single dose.
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