Staff failed to follow multiple provider orders for residents’ meds, monitoring, and treatments. Missed items included pulse ox checks, accuchecks, BP checks before hydralazine, a PPD, ordered meds such as buspirone, lidocaine patch, oxycodone, insulin, hydralazine, sodium chloride, and Aldactone, plus ordered weights, an abdominal binder, a urology consult, and shift pain reassessments. Documentation also showed several ordered interventions were not completed or were not recorded as required.
A resident with a surgical wound infection and right knee replacement did not receive ordered IV antibiotics as scheduled. MAR audits showed Vancomycin and Cefepime doses were often documented hours late, and some Vancomycin doses were left blank at the scheduled time. An RN stated meds are documented on the MAR and are normally given within 1 hour before or after the ordered time, consistent with facility policy.
A resident with dementia, aphasia, dysphagia, and malnutrition had documented decline, low O2 saturation, and ongoing SOB despite oxygen and nebulizer treatments, yet remained in the facility until family chose hospital transfer; the resident was later transitioned to hospice. In a separate case, staff administered Midodrine without evidence in the eMAR of the required BP checks before the dose and one hour after, despite the physician order requiring both monitoring points.
Failure to Administer Ordered Medications and Follow Prescriber Parameters Multiple residents had provider-ordered meds, treatments, or monitoring not carried out as documented in the MAR/TAR. An LPN and other nursing staff recorded missed doses or nonadministration even when meds were available in OTC stock or the Med Bank, including pain, thyroid, vitamin, seizure, COPD, and antibiotic therapies. One resident’s ER antibiotic order was not addressed in a timely manner, and another resident received a beta blocker despite BP being below the hold parameter. A PRN antihypertensive order was also reviewed in relation to BP readings.
An LPN left the west wing without giving report or completing the narcotic count, and no licensed nurse was present on the unit overnight. Residents reported missed bedtime meds, unanswered requests for pain relief, and waiting all night for medications, while MAR review showed no nurse signatures for several scheduled and PRN meds. One resident also reported a pain cream was not applied, and staff described the situation as unsafe because there was no nurse to take over the med cart.
A resident with persistent nausea, vomiting, dizziness, and declining BP did not have the ordered workup consistently completed or documented, including ultrasounds and lab testing, and the chart did not show refusal documentation, discussion of alternatives, or a GI referral despite ongoing symptoms. Nursing notes documented low BP, poor intake, and dizziness, and a later neuro check showed very low BP without physician notification before the resident was found on the floor, became unresponsive, and CPR was initiated.
Failure to Follow Insulin Hold Parameters: A resident with DM2 and multiple comorbidities had an insulin glargine order with a hold parameter for blood glucose less than 200 mg/dL, but nursing documentation showed insulin was given on several occasions when the resident’s blood glucose was below that threshold. The physician and NP continued to document the same hold parameter, yet the MAR later reflected a different instruction to call the provider only if blood sugar was less than 60 or greater than 400, and the DON stated nurses are expected to read and follow the full prescriber order.
Failure to follow hold parameters for Toprol XL: A resident with CHF, COPD, HTN, CAD, prior MI, and moderate cognitive impairment had an order for metoprolol to be held if HR was <60 or BP was <100/60. The MAR documented the medication as given even though the resident’s BP was 94/58, and the ADON agreed it was administered outside the ordered parameters.
An LPN failed to administer multiple ordered meds/treatments to a resident with stroke, DM, HTN, respiratory failure, dysphagia, and GERD during a delayed med pass when the unit was short staffed, and the MAR showed the ordered 9:00 a.m. meds were not given. Staff also failed to document descriptive wound assessments for another resident’s bilateral thigh gunshot wounds; notes and provider entries recorded the wounds and dressing changes, but did not describe wound size, appearance, drainage, odor, or surrounding skin as required by the facility’s wound care policy.
Failure to Administer Ordered Antibiotic Course: A resident with spina bifida, paraplegia, bladder dysfunction, diabetes, and moderate cognitive impairment did not receive a full ordered course of IM ertapenem for a UTI. The MAR showed missed doses and a refusal, the record lacked a note explaining one missed dose, and only 5 of 7 ordered doses were given despite the provider order for daily therapy.
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