A resident with COPD, respiratory failure with hypoxia, and sleep apnea had nebulizer treatments documented as complete even though the nebulizer cup still contained medication during observations. Staff found the nebulizer left assembled on the resident’s end table, and an RN and LPN confirmed medication remained in the cup. A self-administration assessment stated the resident was not safe to self-administer inhalants without supervision, but the record was not updated to reflect that change, and the facility’s nebulizer policy required staff to remain with the resident and clean the equipment after use.
A resident with MS, HTN, neurogenic bladder, COPD, and hyperlipidemia did not receive scheduled 7:00 a.m. medications, and the MAR showed blank boxes for multiple ordered meds including lisinopril, omeprazole, trimethoprim, oxybutynin, baclofen, and gabapentin. The DON confirmed the meds were not administered within the allowable time window and stated medications are expected to be given as ordered.
A resident with intact cognition and diagnoses including a right femur fracture and diabetes received enoxaparin injections ordered for DVT prevention after hip arthroplasty. The MAR listed a calculated end date based on the dispensed quantity, but an RN did not contact the PCP to verify the stop date and no verbal order to stop the med was obtained. The DON stated the end date for enoxaparin should be verified with the provider, and the consulting pharmacist noted that no refills does not always mean the med should be discontinued.
Medication labels for multiple residents were found without an expiration date or beyond use date. An ADON, LPNs, RN, and pharmacists confirmed that labels from both pharmacies did not clearly show when medications should be discarded, and staff were relying on fill dates or general refill timing instead of a visible expiration or BUD on the label.
A resident with prurigo nodularis was prescribed doxycycline 100 mg BID for 10 days, but the order was transcribed with the wrong stop date and the MAR showed the antibiotic continued beyond the ordered duration. Staff interviews confirmed the entry error and that the order should have been verified by a second nurse, but it was entered to discontinue later than prescribed.
Surveyors found that staff did not consistently follow a systematic process to account for controlled medications in the emergency kit and for residents’ home medications stored in the medication room. An RN described using breakaway locks, a binder of lock numbers, and pharmacy usage forms when removing controlled drugs from the e‑kit, but there was no evidence of the every‑shift controlled substance inventory required by policy, and the pharmacist stated the facility should be completing such inventories. Staff, including an RN, an LPN, and a TMA, gave differing accounts of how home medications were handled, often involving placing medications in bags and cabinets, sometimes unlocked, without a standardized method to document all medications and pill counts. These practices did not align with facility policies requiring shift‑to‑shift controlled substance counts by two licensed nurses and proper documentation of medications brought in by residents or responsible parties.
A resident with multiple chronic conditions had provider orders for daily cranberry capsules for UTI prophylaxis and daily lactobacillus for diarrhea, but the facility failed to administer numerous doses over an extended period. MARs showed repeated missed doses of both medications, with nursing notes documenting that the medications were on order, not available, or awaiting pharmacy or house stock delivery. An LPN described the process for documenting unavailable medications and contacting the pharmacy, and the DON described the house stock request process and defined missed doses as medication errors. The NP reported she was not notified about the missed doses, despite expecting to be contacted when medications were not administered as ordered.
Outdated medication was administered from a stock bottle in the med cart when a TMA gave a resident Docusate Sodium without checking the expiration date first. The TMA later saw the bottle was expired, and an LPN confirmed the medication should have been replaced at the end of the prior month. The resident had received doses from the outdated bottle for a total of 24 administrations, and the DON and pharmacist stated staff were expected to follow the 5 rights and not give outdated medication.
Controlled Substance Emergency Kit Not Counted at Shift Change: An RN showed an emergency kit in the med room containing multiple controlled substances that was locked in a cupboard, but it was not included in the shift change narcotic count. The RN stated the kit was swapped out weekly by pharmacy and only documented if used, and the ADON confirmed it was not reconciled at each shift change despite the facility policy requiring narcotics to be securely stored, accurately documented, and reconciled.
Failure to Dispose of Discontinued, Expired, and Discharged Residents’ Medications: Surveyors found medication cards from discharged residents, discontinued orders, and expired OTC medications left in medication storage areas on multiple floors. An RN, LPN, and another RN each stated they were unsure of the medication destruction process, while the DON described a two-nurse destruction process and the facility pharmacist said he was unfamiliar with the current process.
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