Failure to Administer Ordered Medications and Treatments
Penalty
Summary
Surveyors identified that the facility failed to administer physician-ordered medications and treatments to three residents, as evidenced by a review of Medication Administration Records (MAR) and Treatment Administration Records (TAR). Specific missed medications included acetaminophen for chronic pain, levothyroxine for hypothyroidism, megestrol acetate for benign endometrial hyperplasia, and multiple scheduled doses of insulin and blood sugar checks for diabetes management. Additionally, a physician's order to maintain and monitor a chest port for signs of infection every shift was not followed for one resident. These omissions were confirmed by the Director of Nursing (DON) after a review of the records, with no documentation found to indicate the medications or treatments had been provided. The missed administrations occurred on multiple dates and shifts, affecting residents with chronic pain, diabetes, hypothyroidism, and a need for port maintenance. The surveyor discussed the findings with the DON, who acknowledged the lapses, and later with the Regional Director and Consultant RN, who were also made aware of the deficiencies. The report documents that the required medications and treatments were not given as ordered, and the necessary monitoring was not performed, as confirmed by facility leadership.