Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with physician orders for two residents. One resident, admitted with pneumonia and type 1 diabetes mellitus with diabetic polyneuropathy, did not receive scheduled doses of Cefdinir (an antibiotic) and Lantus insulin on the evening of 7/18/25. The resident's blood sugar was subsequently found to be significantly elevated, and the resident was later admitted to the hospital with diabetic ketoacidosis. The DON confirmed that both medications were available and that not administering them constituted a significant medication error. Another resident, admitted with diabetes mellitus and dependence on renal dialysis, had physician orders for sliding scale insulin to be administered three times daily. Review of the medication administration record revealed multiple instances where the 5 PM dose of sliding scale insulin was not provided, either marked as the resident being out of the facility for dialysis or left blank with no documentation. The DON confirmed that the expectation was for blood sugar to be checked and insulin administered after the resident returned from dialysis, and that failure to do so was a significant medication error.