Missed Medication Administrations: A resident had multiple ordered medications omitted without documented reasons, including doses of Simethicone, Gabapentin, Meloxicam, Sertraline, and Pataday eye drops. An LPN believed one medication was out of stock but did not verify availability, while the DON and RN confirmed the medications were available and should have been given as ordered.
A resident with intact cognition, multiple chronic conditions, and an indwelling urinary catheter had an NP and physician order for Clindamycin 1% topical medication to be applied twice daily to a penile erosion site. Review of the TAR showed repeated missing documentation of the evening dose on numerous days within the ordered treatment period, with no recorded reasons for omission. The DON acknowledged the lack of documentation, and an LPN admitted administering the topical medication without documenting it on the TAR, contrary to facility policy requiring documentation of each administered or omitted dose.
A facility failed to document multiple ordered meds, treatments, and monitoring tasks in the EMAR/ETAR for several residents, and also failed to obtain a scheduled PT/INR for one resident. The missing documentation involved wound care, PEG site care, contracture management, oxygen, insulin, diet, pain and symptom monitoring, and other ordered nursing tasks; the ADON and DON confirmed the omissions and stated that if it was not documented, it did not happen.
Failure to Prime Insulin Pen Needles Before Insulin Administration: An LPN administered insulin to residents with DM using insulin pens without priming the pen needle first, despite manufacturer instructions requiring an airshot before each injection to ensure proper dosing. The LPNs confirmed the omission, and the DON stated priming insulin pen needles is standard of care.
A resident with CHF, type 2 DM with circulatory complications, vitamin deficiency, and generalized muscle weakness received a house nutritional supplement multiple times without a documented provider order. An LPN reported obtaining a verbal order from an NP to give 4 oz of house supplement when the resident refused meals but failed to enter the order and could not recall specific administration times. Another LPN later administered the same supplement with morning meds despite no order in the chart and was unsure if it should have been given. The NP confirmed giving a verbal order that should have been entered, and the DON verified there was no documented order, while nurses acknowledged the supplement should not have been administered without it.
Failure to Assess Dialysis Catheter: A resident with ESRD, CKD, and severe cognitive impairment had a dialysis catheter in the left chest wall with a dressing in place, but the record contained no documentation that the CVC was monitored or assessed. The care plan called for monitoring the dialysis access and reporting signs of infection, and an LPN stated the resident had a port for hemodialysis, while the DON confirmed the catheter was not placed on the MAR for monitoring or assessment.
The facility failed to meet professional standards by not assessing, documenting, or reporting multiple skin tears and a forehead abrasion for a cognitively impaired resident, despite existing care plan directives and physician treatment orders for specific wound care. Staff, including the DON, treatment nurse, RN weekend supervisor, and a CNA, acknowledged awareness of injuries such as the resident walking into a wall and prior skin tears, yet there were no incident reports or nursing documentation of these events or initial wound assessments. In addition, the facility did not administer ordered nighttime Tresiba insulin doses to another resident with type 2 DM on multiple occasions, as confirmed by MAR review and the DON, and there was no documentation of any clinical justification for withholding the medication.
The facility failed to ensure antidiabetic medications were administered per physician orders for three residents with diabetes. One resident with type 2 DM did not receive multiple ordered morning doses of Lantus insulin, as confirmed by eMAR review and an LPN interview. Another resident with diabetes mellitus without complications missed a scheduled weekly Ozempic injection, which the responsible LPN acknowledged was not given. A third resident with type 2 DM missed numerous ordered morning doses of Humulin 70/30 insulin, with two LPNs confirming they did not administer the medication on the identified days, and the DON confirming that all three residents should have received their medications as ordered.
Surveyors found that the facility failed to meet professional standards by not completing ordered monthly suprapubic catheter changes for a resident, and by not entering or following wound clinic orders for a Stage 3 gluteal pressure ulcer, resulting in the wound being observed open without a dressing. In addition, another resident with diabetic and chronic foot ulcers had physician wound care orders that were not followed, demonstrating multiple lapses in adherence to ordered catheter and wound treatments by nursing staff, including an LPN and the treatment RN.
A resident with multiple chronic conditions did not receive their prescribed PRN Hydrocodone-Acetaminophen due to the medication not being available. An LPN borrowed the same medication from another resident and administered it, contrary to facility policy and professional standards. The incident was observed by staff and family, and confirmed by the DON and RN Supervisor.
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