LAS VEGAS, NV - Federal inspectors documented multiple instances of nursing staff at Marquis Care at Centennial Hills failing to provide ordered treatments and medications, including borrowing prescription drugs from one resident to give to another, during a July 2024 inspection.
Medication Safety Breach Raises Concerns
During medication administration observation on July 25, 2024, surveyors witnessed a concerning sequence of events involving a diuretic medication prescribed for a resident with Parkinson's disease and heart conditions. The nurse retrieved an empty medication packet for Lasix (furosemide) 40 milligrams from the medication cart and explained the medication was unavailable, requiring an order from the pharmacy.
However, the facility's medication administration record later showed the nurse had documented administering the Lasix to the resident at 9:24 AM that same morning - despite the medication not being in the cart. When questioned, the Director of Nursing confirmed the medication had not been obtained from either the facility's automated dispensing system (Pyxis) or the pharmacy.
The nurse subsequently admitted to borrowing the Lasix from another nurse - medication that belonged to a different resident entirely. This practice violated fundamental medication safety protocols designed to prevent dosing errors, drug interactions, and medication shortages.
Medical implications of this practice are significant. Diuretics like Lasix are prescribed at specific doses based on individual patient needs, kidney function, and other medications. Using another patient's medication bypasses critical safety checks and creates a shortage for the original patient, potentially disrupting their treatment regimen. The practice also violates chain-of-custody requirements that ensure medications can be tracked in case of adverse reactions.
The facility's own policy explicitly stated that "medications supplied for one resident were never to be administered to another resident."
Treatment Documentation Failures Put Residents at Risk
Inspectors identified a pattern of staff documenting treatments as completed when they had not been provided, affecting wound care, compression therapy, and oxygen administration for multiple residents.
One resident admitted with a skin tear on the right forearm had physician orders for wound treatment every three days. When surveyors observed the resident on July 23, the wound dressing was dated July 18 and visibly peeling off. The treatment record indicated the wound care nurse had successfully provided treatment on July 21, but the old, deteriorating dressing contradicted this documentation.
The wound care nurse later admitted the treatment scheduled for July 21 was not provided but was inaccurately documented as completed. The nurse initially edited the record to show the resident "refused" treatment, but then clarified the resident was actually asleep and had not refused anything. The physician was never notified about the missed treatment, and accurate documentation was not maintained for three days.
Proper wound care is critical for healing and infection prevention. Delays in treatment can extend healing time, increase infection risk, and potentially allow minor wounds to progress to more serious complications, particularly in elderly residents with compromised healing capacity.
The same resident faced additional treatment gaps. Despite physician orders for elastic compression wraps (ACE wraps) to be applied to both legs at 8:00 AM daily to treat swelling, the wraps were found lying on the bedside table on July 23 - not applied to the resident. The medication administration record showed the wraps had been applied and were in place, another instance of false documentation.
Compression therapy serves important medical purposes for residents with edema. The wraps help improve circulation, reduce fluid accumulation in tissues, and prevent complications associated with poor venous return. When not applied as ordered, residents may experience increased swelling, discomfort, and elevated risk of skin breakdown or blood clots.
Staff confusion about responsibility for applying the wraps compounded the problem. Certified nursing assistants believed licensed nurses were responsible, while nurses indicated CNAs should apply them. This lack of role clarity resulted in the treatment simply not being provided, despite documentation to the contrary.
Oxygen Administration Discrepancies
The same resident was prescribed oxygen at 2-4 liters per minute via nasal cannula for chronic obstructive pulmonary disease (COPD). On two separate observations, the oxygen was flowing at 5 liters per minute - above the ordered range - while documentation indicated it was being administered at 3 liters per minute.
The licensed nurse admitted to not checking the actual flow rate before documenting it in the medication record. Oxygen administration rates are prescribed based on specific medical conditions and blood oxygen levels. For COPD patients, excessive oxygen can potentially suppress respiratory drive, a serious safety concern. Conversely, inadequate oxygen can lead to tissue hypoxia and organ damage.
The facility's oxygen administration policy required staff to verify physician orders and assess residents before and during oxygen therapy - steps that were not consistently followed.
Nutritional Support Failures
A tube feeding-dependent resident admitted on July 22 did not receive ordered nutrition or hydration for nearly 24 hours following admission. The resident required 1,080 milliliters of water flushes daily through the feeding tube, plus tube feeding formula to meet nutritional needs.
Staff hung a bag of water at 7:30 PM on the admission date, but it remained full and not infusing more than 24 hours later. The resident reported experiencing dry mouth and throat discomfort, requesting water to help clear phlegm. Despite a speech therapist assessing the resident as safe to take small sips of water by mouth under supervision, nursing staff declined to provide this comfort measure.
The tube feeding formula presented additional problems. Staff initially provided the wrong formula (Glucerna instead of the ordered Diabetisource), and when the resident experienced stomach discomfort, the feeding was held without notifying the physician or dietitian to obtain alternative orders.
Prolonged deprivation of nutrition and hydration can lead to dehydration, electrolyte imbalances, decreased immune function, and delayed healing. For residents dependent on tube feeding, timely administration is essential for maintaining metabolic function and overall health status.
Post-Fall Assessment Omitted
When a resident reported experiencing a fall several days after it occurred, nursing staff failed to complete required post-fall assessments and neurological checks. The resident reported falling asleep at the edge of the bed and falling onto the right side, with subsequent hip and leg soreness.
Post-fall assessments serve critical medical purposes. They help identify fractures, head injuries, and internal bleeding that may not be immediately apparent. Neurological checks monitor for signs of traumatic brain injury, which can manifest hours or days after impact. The absence of these assessments meant potential injuries went undetected and untreated.
The resident's increasing hip pain in subsequent days raised questions about whether the fall contributed to the discomfort - questions that proper assessment could have addressed immediately.
Additional Issues Identified
Inspectors documented several other deficiencies during the survey:
Pressure ulcer prevention: One resident with physician orders to keep heels elevated off the bed surface (floating heels) was observed on two separate occasions without heel protectors and with heels resting directly on the mattress, despite being at moderate risk for pressure injuries.
Weight monitoring: A resident on weekly weight monitoring due to weight loss had no weight recorded for the entire month of April 2024, resulting in a 26-pound weight loss going undetected for two months. The resident was on diuretics and had conditions requiring close weight monitoring.
Food safety: Kitchen inspection revealed multiple open food containers lacking date labels, and inspectors found 11 cantaloupes and one watermelon showing signs of spoilage with black spots, white patches, and soft, mushy texture still in storage rather than discarded.
The patterns documented during this inspection revealed systemic issues with treatment implementation, documentation accuracy, and staff accountability that extended across multiple departments and affected numerous residents at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marquis Care At Centennial Hills from 2024-07-26 including all violations, facility responses, and corrective action plans.
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