Two residents had PRN acetaminophen given without consistent documentation of NPI attempts before administration. One resident with dementia and a right arm fracture had acetaminophen given multiple times, but the interventions were marked not applicable. Another resident with HTN, anxiety, and osteoporosis received acetaminophen for pain, but not applicable was documented instead of an NPI code, and no NPIs were recorded.
Digoxin Given Despite Low HR: A resident with chronic atrial fibrillation received Digoxin even when the HR was below 60 bpm on multiple occasions. The EMAR showed the medication was administered despite low HR readings, and the DON and an RN confirmed the drug should have been held and the provider notified.
A resident with anxiety and depression, documented as alert and oriented, had a physician order for Haldol 2 mg daily that was to be held pending clarification. Despite this hold instruction and without obtaining consent, staff administered Haldol as recorded on the EMAR. The resident’s family contact reported the resident was not supposed to receive Haldol due to concerns about hand tremors, and the Administrator/RN confirmed that the psychotropic medication had been given without the required consent.
A resident with moderate cognitive impairment had a lidocaine patch order that was transcribed and carried out as 24-hour continuous use instead of the intended 12 hours on and 12 hours off. The patch was applied daily for 13 administrations, and the resident and multiple nurses stated this was not the correct wear schedule; the DON acknowledged the provider intended only 12 hours of use.
A resident’s metoprolol was administered despite a physician order to hold the medication when systolic BP was below 110. Review of the MAR showed multiple doses were given when the resident’s systolic BP was under the ordered parameter, and an LPN acknowledged the medication should have been held; the DON stated staff were expected to follow the BP parameters and notify the provider.
PRN pain meds were given without documented NPI use for one resident with pain orders and another cognitively intact resident with pain orders, and oxycodone was also administered outside the ordered pain range. In addition, two residents with cardiac/heart failure-related med orders received eplerenone, torsemide, or metoprolol despite BP readings below the prescribed hold parameters. The DON and Administrator acknowledged the meds were given outside the ordered parameters.
A resident with atrial fibrillation was receiving Eliquis daily and was later started on Naproxen 250 mg BID for pain, ordered by the MD as a two-week short course. The RCM entered the Naproxen order into the MAR without an end date, and the medication continued to be administered BID until the resident was discharged. Staff later identified extensive bruising to the resident’s inner thighs, buttocks, and perineal area, and the DON acknowledged that the ongoing concurrent use of Eliquis and Naproxen, despite the intended time-limited order, could have contributed to the bruising.
A resident with moderately impaired daily decision-making had a PRN Hydrocodone-Acetaminophen order for moderate to severe pain with a pain score of 6-10, but the MAR showed the medication was given 42 times outside the ordered parameters when documented pain scores were below 6. The Unit Manager/LPN acknowledged the doses should not have been given outside parameters, and the DON stated the practice did not meet expectations.
Unnecessary PRN pain medication use and failure to follow medication parameters: The facility did not follow provider orders for PRN pain meds and BP med hold parameters for several residents. An LPN and the DON/DNS confirmed that NPI were not offered or documented before multiple PRN doses of opioids, acetaminophen, ibuprofen, and a muscle relaxant, and one resident received antihypertensives despite a low HR. Another resident’s Tylenol dose was documented without the required NPI notation.
The facility failed to keep residents free from unnecessary drugs for three residents. A resident with cancer and pain had PRN pain orders with non-pharmacological interventions, but the MAR did not document that those interventions were provided. A resident with chronic lung disease remained on O2 despite repeated room-air SpO2 checks above the ordered threshold, and the RCM confirmed the physician was not contacted to trial RA. Another resident with chronic pain received oxycodone outside ordered pain parameters, and documentation of non-pharmacological interventions was inconsistent or unavailable.
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