Failure to Initiate Physician-Ordered Medication
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Nurses at the facility failed to initiate a physician-ordered medication, Naltrexone, for a resident with a history of severe dementia, psychotic disturbance, and hypersexual behavior, as documented in a psychiatric evaluation. The resident, who also had a PEG tube for nutrition and other significant diagnoses, was recommended to start a trial of Naltrexone 25 mg daily to address inappropriate behavior. Review of the resident's July 2025 medication administration record showed that the medication was never started as ordered. During an interview, the DON confirmed that the medication had not been initiated and acknowledged that it should have been.