Medication administration was not performed according to orders and facility procedures for three residents. An RN gave morphine to one resident outside the ordered respiratory-rate and pain parameters, an LPN administered multiple G-tube meds by pushing them with the syringe plunger instead of gravity delivery, and an RN gave a Breyna inhaler without offering mouth rinsing afterward.
The facility failed to follow professional standards for medication administration and weight monitoring. An LPN discontinued Eliquis for a resident without a new order, and another resident missed Pyridostigmine doses without documented hold parameters or provider notification. The facility also did not re-weigh residents after a large weight gain and a large weight loss, including a resident with severe protein-calorie malnutrition.
Failure to follow a wound care order for a healed skin tear. A resident’s left forearm skin tear was documented as healed and open to air, yet a dated kerlix dressing remained in place on later observations even though the order had been discontinued. An LPN confirmed the wound was healed and no longer needed a dressing.
Failure to follow medication hold parameters for two residents. A resident received Norvasc despite SBP readings below the ordered hold limit, and another resident received Insulin Glargine despite CBG readings below the ordered hold limit. The DON confirmed the Norvasc issue, and the NP stated the insulin should not be given outside the ordered parameters.
The facility failed to meet professional standards of quality by not documenting required post-fall assessments for two residents. In one case, a resident was found on the floor with head and leg pain, a lump on the head, and later increased right leg pain after being moved to bed; although an RN reported performing an assessment, there was no documentation of that assessment, no recorded VS, and no neuro checks despite the resident remaining in the facility for hours before ER transfer. In the second case, a resident was found on the floor after attempting an independent transfer, noted as having no skin issues and moved to a w/c, with an IDT note later referencing a full body assessment by the unit manager; however, no detailed assessment, VS, or injury documentation was found in the record. These omissions conflicted with facility policies requiring documentation of the resident’s condition, assessment data, VS, and interventions after a fall.
A resident received the wrong Fluticasone product during med pass when an LPN gave nasal spray instead of the ordered inhaler. In a separate issue, another resident with orders for daily weights related to edema and CHF had multiple missed weight entries on the MAR, with no documentation of refusal or provider notification.
Medication administration was not consistent with prescriber orders and manufacturer instructions for three residents. One resident had an elevated blood sugar that required provider notification, but no notification was documented; another resident received metoprolol despite BP readings below the hold parameter; and a third resident had Wellbutrin XL crushed even though it was labeled not to be crushed, while Baclofen doses were given late and too close together.
An LPN administered Pataday 0.2% eye drops to a resident even though the bottle was beyond the manufacturer’s 4-week discard period after opening. The LPN confirmed the finding, and the facility’s med administration policy requires checking the expiration or beyond-use date before giving meds.
Medication administration standards were not followed for three residents. One resident missed documented blood sugars and insulin doses despite an order for sliding-scale insulin. Another resident with a nicotine patch was also smoking, and staff removed the patch before smoking even though the NP was unaware of the ongoing smoking. A third resident with a J-tube received crushed lamotrigine despite a do-not-crush label, and the LPN did not verify tube placement before administering meds.
A resident with insulin orders had a sliding-scale dose given for a CBG over 351, a scheduled 15-unit dose held, and another sliding-scale dose given later for a blood sugar of 469. Staff documented the held dose and the resident's poor intake and drowsiness, but there was no documentation of provider notification for the high CBG, no entry in the provider communication book, and an LPN confirmed the evening insulin was given without notifying a provider.
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