A resident admitted with respiratory failure, anxiety, and ventilator dependence did not receive ordered anxiolytic medication as documented. The MAR showed Clonazepam was held and later not administered because it was awaiting pharmacy delivery and none was in the Pyxis, while an Alprazolam substitute was ordered but not documented as given. Staff gave conflicting accounts about whether the physician or pharmacy was contacted, and the pharmacist later reported Clonazepam was actually on hand in the ADC and no stat delivery was requested.
Missing controlled substance count signatures and delayed narcotic documentation. Review of narcotic count books showed multiple missing signatures on two units, including periods with no signatures for several shifts. During a med pass, an LPN did not immediately sign the narcotic record after giving two narcotic meds. Staff, including the DON, stated the count should be signed each shift and narcotics should be documented when administered.
Missing Controlled Substance Reconciliation: A resident with dementia and severely impaired cognition had Oxycodone 10 mg dispensed, received, and later changed from a standing order to PRN after lethargy. The blister pack with the remaining tablets and the count sheet were later missing from the locked narcotic box, and staff gave conflicting accounts about counting, holding, transferring, and removing the medication. Searches of medication areas and review of destruction records did not locate the narcotic, and the facility documented suspected diversion.
Incomplete and premature narcotic count signatures were found on multiple unit narcotic count records. Surveyors identified missing oncoming and outgoing nurse signatures and instances where LPNs signed the narcotic count book in advance for future shifts. Interviews confirmed that some nurses signed early, some had not signed yet, and the DON acknowledged ongoing audits due to missing signatures and advance signing.
Controlled Substance Log Signed Before Administration: An LPN signed the narcotic log in advance for scheduled controlled meds for five residents, including opioid and antianxiety doses that were not yet due. The facility policy required accountability and security for controlled substances, but it did not describe the documentation process for administration on the log. The RN unit manager stated the log should be signed only after the med was given, not for the whole shift at the start.
An LPN administered morning meds to multiple residents well outside the ordered time window, with several 8:30 AM meds documented around 11:37 AM to 11:55 AM. The DON, physician, and medical director stated meds should generally be given within one hour before or after the ordered time, while the LPN said they were unfamiliar with the unit and the unit manager said they were occupied with treatments and did not realize 12 residents still needed morning meds.
Medication administration was not accurate or timely for several residents. A resident on dialysis missed repeated Renvela doses when away from the facility, with no documented provider notification and no pharmacist review of the missed doses. Three residents with Parkinson’s disease also received carbidopa-levodopa late or not at all as ordered, including one case where a pill cup with the prior evening’s meds was left at the bedside overnight and other cases where LPNs gave time-sensitive doses outside the ordered window without prior provider notification.
Failure to Administer Ordered Medications and Treatments: Two residents did not receive ordered meds/treatments as scheduled. One resident with bipolar disorder missed quetiapine doses when the pharmacy had not delivered the medication, and the record did not show pharmacy follow-up, MD notification, or alternate orders. Another resident with chronic pain missed lidocaine patch applications when the resident was already out of bed, with no later attempt documented and no MD notification or alternate instructions noted.
Crushed Extended-Release Potassium Chloride: An LPN crushed an extended-release potassium chloride tablet and mixed it in applesauce before giving it to a resident with cancer, DM, and osteomyelitis. The blister pack stated do not crush and noted the tablet could be dissolved in water before administration. The LPN said they did not realize the label said not to crush it, and the pharmacist, nursing educator, and DON all confirmed the medication should not have been crushed.
Incomplete controlled substance count signatures were found on narcotic records for multiple units, with missing signatures from both oncoming and off-going nurses during shift counts. The facility policy required controlled meds to be counted at the end of each shift and signed by both nurses, and an LPN stated the narcotic book should be signed during the narcotic count and key hand-off at the beginning and end of every shift.
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