Failure to Administer Medication per Physician's Orders
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders regarding medication administration for one resident. The facility's policy required that medications be administered by licensed nurses as ordered by the physician. The resident, who was cognitively intact and had a diagnosis of heart failure, had a physician's order to receive 50 mg of Metoprolol Succinate daily for hypertension. On March 6, 2025, the physician reviewed the resident's medications and ordered the Metoprolol dose to be decreased to 25 mg daily. However, the new order for 25 mg of Metoprolol was not added to the Medication Administration Record (MAR), resulting in the resident not receiving any Metoprolol Succinate from March 7, 2025, to July 28, 2025. This lapse was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the medication order change was not implemented and the resident did not receive the prescribed medication during this period.