A nurse failed to follow facility policy when preparing and administering insulin pens for a resident receiving Lantus and Novolog. The nurse attached new needles without wiping the pen tips with alcohol, dialed the pens to 2 units while holding them horizontally, and primed them with the needle covers still on. An administrative nurse confirmed the expected practice was to clean the pen before attaching the needle and prime it with the needle upright.
A resident was observed with a medication cup containing several pills on the bedside table after staff documented the morning med pass. Facility policy required staff to remain with the resident until meds were taken and swallowed unless there was a specific physician order to leave them at the bedside, and an administrative nurse stated the resident was not appropriate to self-administer medications.
A resident with a PEG tube had a morphine order for buccal use or via PEG tube, but the MAR was transcribed as buccal only. During med pass, an RN administered the morphine through the PEG tube, which did not match the MAR entry. An administrative nurse confirmed the order was not accurately transcribed.
Staff did not follow physician orders for two residents and did not follow enteral tube medication procedure for another resident. One resident with DM had blood sugars above the call-MD threshold without documentation that the provider was notified, and another resident with CKD on dialysis had multiple weight changes beyond the ordered 4-lb range without provider notification. In a separate event, an RN crushed medication and poured it into a resident’s PEG tube without diluting it first, contrary to facility policy.
A resident with atrial fibrillation had a faxed anticoagulation clinic order for Warfarin 7.5 mg on Monday and Friday and 5 mg on the other days, but the EHR was entered as 7.5 mg on Monday and Tuesday and 5 mg on the other five days. Staff confirmed one nurse incorrectly transcribed the order and another nurse failed to verify it before changing it in the EHR.
Improper mixing of a NovoLog 70/30 insulin pen occurred during medication administration for a resident when an MA primed and immediately administered the insulin without following the required mixing protocol. Facility policy and the manufacturer’s instructions both required the pen to be rolled and turned before use, and a staff nurse later stated she was unaware of the mixing process for this insulin pen.
Failure to follow medication administration standards was observed for two residents during med pass. An RN gave Pataday eye drops and then Xiidra eye drops to a resident only two minutes later, instead of waiting at least five minutes between ophthalmic products. In a separate event, an RN prepared an insulin pen for another resident without wiping the rubber seal with an alcohol swab before attaching the needle, contrary to facility policy.
A resident who was documented as taking meds whole was observed receiving crushed meds mixed in pudding without a provider order. The MAR did not show an order to crush the meds, and an LPN stated the meds had been crushed for weeks since the resident returned from the hospital after a stroke.
Medication administration errors were observed for two residents. One resident’s Gabapentin was documented as given at the scheduled time even though it was actually administered later, and another resident with DM and insulin dependence had an insulin pen primed incorrectly by an LPN. The facility also lacked a policy on medication administration and documentation.
Two residents requiring modified diets and direct or 1:1 supervision during meals were observed eating without the required staff supervision and with access to straws, despite physician orders and care plans specifying otherwise. Staff confirmed these orders were not followed during the observed mealtimes.
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