Failure to Administer Medications and Perform Required Care as Ordered
Penalty
Summary
The facility failed to administer medications and perform required care interventions according to physician's orders for a resident diagnosed with unspecified dementia, paranoid schizophrenia, and depression. The resident was assessed as cognitively impaired and required significant assistance with daily activities. The care plan included administration of multiple psychotropic medications and monitoring for therapeutic effects and side effects, as well as completion of behavior monitoring sheets every shift. However, review of the Medication Administration Records (MAR) for May 2025 revealed that several medications, including Haloperidol, Melatonin, Mirtazapine, Trazadone, Guaifenesin ER, Acetaminophen Extra Strength, and Morphine, were not administered as ordered on specific dates. There was no documentation in the nursing notes indicating that the resident refused these medications. Additionally, the MAR indicated that other required care interventions, such as administration of Ensure Plus, pain assessments, assessments for shortness of breath, monitoring for signs and symptoms of antidepressant use, and application of compression stockings or ace wraps, were not performed on certain dates. Again, there was no documentation of refusal by the resident. Facility policy requires that medications be administered as prescribed and that any refusals or withheld doses be properly documented on the MAR. An interview with the ADNS confirmed the expectation for accurate documentation of medication administration and refusals.