Expired Vitamin B12 was administered to a resident after an MA gave a daily dose from a medication cart bottle that had an expiration date of 1/2026 and still contained 92 pills. During the med storage observation, the MA stated she had already given the expired dose that morning and admitted she did not check the expiration date before administration. The MAR confirmed the resident received the Vitamin B12, and the DON and Administrator stated their expectation was that residents receive non-expired medications.
Failure to Provide Ordered Moisture-Associated Skin Treatment: A resident with moisture associated skin damage and urinary incontinence was ordered daily interdry under the abdominal folds, but staff documented the treatment as completed when it was not actually applied. The resident reported the supply had run out and a dry bath towel was being used instead; observations confirmed a towel in the folds, later saturated with urine. The DON, treatment nurse, and MD all stated the treatment should not have been signed off if it was not performed, and the towel was not an acceptable long-term substitute.
A resident with DM received insulin lispro outside the ordered BG parameters on multiple occasions. Staff gave half doses even when BG values were above the threshold for dose reduction, and an RN confirmed several of the discrepancies. The Medical Director and DON stated staff were expected to follow the physician’s orders as written.
Wrong Resident Transported to Scheduled Appointment: A resident with HF and impaired mobility was prepared for an ortho appt, but a transport driver picked up the resident’s roommate instead. The wrong resident was taken to the appt, identified there as not being the scheduled patient, and returned to the facility while the intended resident never arrived.
Wrong Resident Received Scheduled Medications: A medication aide gave one resident another resident’s scheduled meds, including doxepin, lamotrigine, folic acid, and acetaminophen, after the aide entered a room with only one name on the door, the curtain blocked the second bed, and the room change had not been updated in the computer system. The aide called out the intended resident’s name, got a response from the resident in bed A, and administered the meds before realizing the error. The resident who received the meds was monitored, remained sleepy but easily aroused, and later went to the ER; labs and EKG were normal, and the NP later noted the resident was back to baseline.
A medication aide left after only a few hours, and two nurses stated they did not give medications to residents on two halls for several hours afterward. As a result, multiple residents missed scheduled doses of Parkinson’s meds, antihypertensive therapy, buspirone, depakote, acetaminophen, and glaucoma eye drops that were ordered by the MD.
Failure to Implement Abdominal Wound Care Orders: A resident admitted after abdominal surgery with DM had wound care orders in the hospital discharge summary and later from the Wound Care NP, but the orders were not entered into the TAR right away and wound care was not documented for several days. The resident reported that after soiling the dressings, a nurse refused to change them, and she cleaned the incisions herself and left them open to air before wound care was finally started.
A resident with peripheral vascular disease and a left above-knee amputation, who was moderately cognitively impaired and receiving PRN opioid analgesia for pain, had a Hydrocodone/Acetaminophen order changed from 10 mg/325 mg to 5 mg/325 mg every 6 hours PRN. The MAR for the month showed both the discontinued 10 mg/325 mg order and the new 5 mg/325 mg order, and review of the controlled substance declining count sheets revealed that nurses repeatedly removed 10 mg/325 mg tablets while documenting administration of 5 mg/325 mg on the MAR, and on two occasions removed 10 mg/325 mg tablets with no corresponding MAR entry. The NP confirmed the resident should have been receiving only the 5 mg/325 mg dose during this period, and the DON stated the discontinued 10 mg/325 mg supply and count sheet should have been removed when the order was changed.
Late Medication Administration for Two Residents: Two residents had scheduled meds given well outside the expected timeframe after an agency RN fell behind during morning med pass and did not request help. One resident with HTN received Hydralazine and Metoprolol late, and another resident with neuropathic pain received Neurontin late. The NP confirmed both residents had no ill effects and remained clinically unaffected.
A resident with multiple chronic conditions and a medication regimen including anticoagulant, beta blocker, diuretic, thyroid replacement, psychotropics, and opioid pain medication had a cup of pills found unattended on her bed. The resident was blind and stated she did not know the medication was there, while an RN and the DON said staff should not leave meds in a resident room and that the resident was not coded for self-administration. The facility could not determine when or by whom the pills were left or whether they were the resident’s medications.
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