Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
A deficiency was identified when a resident with a medical history of kidney failure, congestive heart failure, COPD, depression, and chronic pain did not receive multiple medications and treatments as ordered by their physician. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for March 2025 revealed several missed doses of prescribed medications, including Mirtazapine, Rocklatan Ophthalmic Solution, Buspirone, and Trospium Chloride. Additionally, required monitoring and treatments such as behavior monitoring for medication side effects, fluid restriction for CHF, oxygen therapy, pain and vital signs monitoring, wound care, topical applications, and use of pressure-reducing devices were not completed on multiple occasions. The Director of Nursing (DON) confirmed upon review that the medications and treatments had not been administered on the specified dates. The Nursing Home Administrator (NHA) was also made aware of the issue and acknowledged the concern regarding the failure to provide care and treatment as ordered. The deficiency was based on direct record review and staff interviews, which verified that the resident did not receive the required medications and treatments according to physician orders.