Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered vital signs, medications, and interventions for two of three residents reviewed (Residents 1 and 2).Findings include:
Clinical record review for Resident 1 revealed a current physician's order for staff to administer Cinnamon 500 milligrams (mg) one tablet by mouth (PO) daily for diabetes mellitus and Chromium 200 micrograms (mcg) PO daily for diabetes mellitus.
Review of Resident 1's January and February 2024 MAR (medication administration record, a form to document medication administration) revealed staff were administering his Cinnamon and Chromium medications daily with the Chromium being held 14 times and the Cinnamon being held 14 times in January. Neither medication was held in February. There was no documentation in Resident 1's nursing documentation that indicated justification as to why both medications were held.
Observation of a facility medication cart on February 7, 2024, at 1:25 PM with Employee 1, licensed practical nurse, confirmed that the facility had Chromium 1000 mcg (not 200 mcg as ordered and five times the ordered dose) and Cinnamon 1000 mg (not 500 mg as ordered and twice the ordered dose) available for administration for Resident 1. Employee 1 acknowledged that she administered both medications to Resident 1 and failed to identify the incorrect milligram and/or microgram dosage for each medication.
Observation of the same facility medication cart on February 7, 2024, at 2:32 PM with Employee 1 and the Nursing Home Administrator (NHA) revealed that there was an unopened bottle of Cinnamon 500 mg (Resident 1's correct physician ordered dosage) upside down in the bottom drawer of the cart where other overflow/overstock medications are stored. The NHA revealed that he had purchased the over-the-counter Cinnamon 500 mg bottle at a local business over this past weekend and provided it to nursing staff on February 5, 2024, upon return to work. Employee 1 revealed that she was unaware that the correct Cinnamon dosage was available to administer to Resident 1.
The facility failed to procure and administer the correct dosage of Resident 1's Cinnamon and Chromium medications and failed to identify an incorrect dosage prior to administering Resident 1 medications.
Clinical record review for Resident 2 revealed a current physician's order for staff to monitor their blood pressure BP (blood pressure) medications if her systolic blood pressure (pressure when the heart contracts) was less than 100 mmHg (millimeters of Mercury) and diastolic blood pressure (pressure when the heart rests) was less than 60 mmHg. Resident 2's physician ordered Lisinopril (for high blood pressure) 5 mg PO daily and Carvedilol (for high blood pressure) 12.5 mg PO twice daily.
Review of Resident 2's clinical documentation revealed that staff documented her blood pressure as less than physician ordered parameters, but administered her Carvedilol and/or Lisinopril on the following dates:
January 12, 2024, at 10:50 AM 94/50 mmHg
January 13, 2024, at 10:15 AM 95/55 mmHg
January 13, 2024, at 7:31 PM 94/58 mmHg
January 14, 2024, at 11:49 AM 96/59 mmHg
January 18, 2024, at 7:45 PM 86/49 mmHg
January 19, 2024, at 9:28 AM 89/59 mmHg
January 20, 2024, at 12:48 PM 87/54 mmHg
January 23, 2024, at 9:50 AM 84/59 mmHg
January 23, 2024, at 8:47 PM 88/54 mmHg
January 24, 2024, at 7:22 PM 98/60 mmHg
January 26, 2024, at 9:27 AM 80/58 mmHg
January 27, 2024, at 9:06 AM 80/58 mmHg
Further review of Resident 2's clinical documentation revealed that there was no documentation of her blood pressure on the following dates; however, staff administered her Lisinopril and/or Carvedilol :
January 22, 2024, 8:00 PM
January 25, 2024, 8:00 PM
January 26, 2024, 8:00 PM
February 3, 2024, 8:00 PM
February 4, 2024, 8:00 AM
The surveyor reviewed the above information during an interview on February 7, 2024, at 2:10 AM, with the Nursing Home Administrator.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services