Insulin Administered Too Early Before Meal
Summary
A patient with diabetes mellitus, who was cognitively intact and required some assistance with daily activities, was prescribed insulin lispro to be administered subcutaneously 15 minutes before meals and at bedtime, according to a sliding scale based on blood glucose levels. On the day in question, the patient received 8 units of insulin lispro at 4:00 p.m. for a blood sugar reading of 301 mg/dL, prior to the scheduled dinner. The patient's care plan specified that diabetes medication should be given as ordered by the physician. Observation and interviews revealed that the insulin was administered significantly earlier than the prescribed time, as the patient had not yet received the dinner meal more than an hour after the injection. The nurse who administered the insulin stated that it could be given up to an hour before the meal and did not provide a snack to the patient before dinner, citing being busy with other tasks. Facility policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in this instance.
Plan Of Correction
C900: T22 DIV5 ART3-72313(a)(2) Nursing Service - Administration of Medication Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, DON assessed Patient 7 for any adverse reactions related to the early administration of insulin lispro. There was no change in condition noted. Identify any other residents who may have been affected by the deficient practice. On 3/12/2025, MRD audited the last 7 days of insulin administration to ascertain if any other patients had been given insulin before it was due. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, in-servicing of licensed nurses regarding the proper timing and administration of insulin was initiated. (To continue page 5 of 25) continued Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check insulin administrations of 5 patients per week to ensure they are not being administered before they are due. These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed. 04/03/25 C 900
Penalty
A resident with respiratory failure and chronic lung conditions received supplemental oxygen outside the prescribed saturation range on multiple occasions, with staff failing to notify the physician as required by the order. The DON confirmed that the facility did not follow the prescribed oxygen administration parameters.
A nurse failed to ensure that a resident with multiple medical conditions received medications according to physician orders, including not providing required food or fluids with certain medications, not instructing the resident to rinse her mouth after inhaler use, and allowing self-administration without a physician's order or proper supervision.
A resident with respiratory failure and COPD did not receive continuous oxygen therapy as ordered by the physician. Records showed the resident was frequently on room air instead of oxygen, and observations confirmed the oxygen flow was set below the prescribed rate. Facility staff acknowledged the physician's order was not followed, contrary to facility policy.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
Facility staff failed to administer supplemental oxygen as prescribed for one resident with acute and chronic respiratory failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. The resident's care plan and physician's orders specified that oxygen saturation should be maintained between 88% and 94%. However, review of the Medication Administration Records (MAR) revealed that on 66 out of 84 documented occasions, the resident's oxygen saturation was above 94% and the physician was not notified as required by the order. The Director of Nursing confirmed that staff did not follow the prescribed parameters for oxygen administration and failed to notify the physician when the resident's oxygen saturation exceeded the ordered range. The facility's policy required staff to verify and review physician orders for safe oxygen administration, but this was not adhered to in this case.
Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a patient as prescribed by the physician. The patient, who had diagnoses including dysphagia, asthma, chronic respiratory failure with hypoxia, COPD, and lack of coordination, required specific administration instructions for several medications. During a medication pass, the nurse prepared and provided the medications to the patient but did not ensure that the medications were taken according to the physician's orders. Specifically, the patient did not take Metoprolol with food, did not take Potassium Chloride with the prescribed four to six ounces of water, and did not rinse her mouth after using the Pulmicort inhaler. The nurse also did not provide instructions or directions for the use of these medications and left the room before confirming that the patient had followed the required steps. The patient's care plan included interventions for swallowing problems, asthma/COPD, and nutritional risk, all of which required staff to monitor and assist with medication administration and hydration. Despite these documented needs, the nurse allowed the patient to self-administer medications without a physician's order for self-administration and without providing the necessary assistance or supervision. The nurse also failed to notify the physician when medications were not administered as prescribed, such as when Metoprolol was given more than two hours after the scheduled time and without food. Facility policy required medications to be administered as prescribed, within the appropriate time frame, and with adherence to any special instructions, such as taking medications with food or fluids and rinsing the mouth after inhaler use. The policy also specified that self-administration of medications must be authorized by the physician and documented in the care plan. In this case, the nurse did not follow these policies, resulting in the patient not receiving medications in accordance with physician orders.
Plan Of Correction
C 0900 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025 the RN supervisor immediately assessed patient 9 for any signs of adverse outcome regarding medications that were not administered per MD orders. Vital signs were taken and recorded as follows: BP=139/76, P=68, R=16, O2 Sat=96% and Pain level=0/10. Patient 9 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. RN supervisor provided patient 9 with education on proper method of taking her medication. Patient verbalized understanding. 2. On 10/7/2025 DON initiated and completed a one-on-one in-service with LVN 4 respectively to discuss the policy and procedure (P/P) on medication administration. The emphasis was on accurately following MD orders for specific medications as per MD order and/or pharmaceutical recommendation (i.e. with food with sufficient fluids, rinsing mouth between medications, etc.) DON also discussed the potential of unwanted effects from medications being administered incorrection. DON reiterated the importance of "pour, pass, and sign" medication administration procedure. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025 upon identification of deficient practice, DON, ADON, and RN Supervisor immediately completed a facility round to observe all other charge nurses during medication pass to ensure residents' medications are being administered as ordered. No additional residents were affected by the deficient practice. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025 DON completed an in-service for all nursing staff on "Medication Administration" P/P, how to handle patients with medication refusals, importance of "pour, pass, sign," and MD/RP notification prior to administration of any additional doses. The discussion was followed by question-and-answer evaluation. On 10/30/2025 facility implemented a medication pass audit that will be completed weekly at random selection by the DON, ADON and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C0900
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed for one patient with significant respiratory conditions. The patient, who had diagnoses including respiratory failure, COPD, pleural effusion, and was receiving palliative care, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula or mask to maintain oxygen saturation above 90%. However, record reviews showed multiple instances where the patient was documented as being on room air instead of receiving continuous oxygen. Additionally, direct observations revealed the oxygen flow was set below the prescribed rate, at 1 to 1.5 liters per minute, rather than the ordered 2 liters per minute. Interviews with facility staff, including the ADON, LVN, IPN, and DON, confirmed that the physician's order for continuous oxygen was not followed. Staff acknowledged that the patient was not consistently provided with the ordered oxygen therapy and that the oxygen flow rate was not set as prescribed. The facility's policy and procedure on oxygen administration required adherence to physician orders, but this was not maintained in the care of this patient.
Plan Of Correction
Nursing Service--Administration of Medication How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, Patient 6's oxygen setting was corrected and adjusted to 2 L/min as ordered by the physician. - On 9/24/25, the Assistant Director of Nursing (ADON) provided a one-on-one in-service to LVN #2 regarding accurate oxygen administration in accordance with physician orders. - On 9/24/25, the ADON and Director of Staff Development (DSD) conducted an in-service for Licensed Nurses, CNAs, and staff on proper oxygen administration practices per physician orders and the facility's Oxygen Policy and Procedure. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 09/24/25, the Assistant Director of Nursing (ADON) conducted rounds on all residents receiving oxygen therapy to verify that oxygen settings were consistent with current physician orders. - No other residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/15/25-10/16/25, the ADON and DSD conducted in-service training for all Licensed Nurses, Certified Nursing Assistants (CNAs), and staff on accurate oxygen administration in accordance with physician orders and the facility's Policy and Procedure on Oxygen Use. - Starting 10/13/2025, the ADON and/or DSD will conduct random rounds 3x/week for 3 months to monitor compliance with proper oxygen administration per physician orders. Any findings identified during the rounds will be addressed promptly, and reeducation will be provided as necessary. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The ADON and/or DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
