Failure to Follow Physician's Orders for Medication Administration
Penalty
Fine: $47,51420 days payment denial
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
Staff failed to follow a physician's order for a resident with dementia and hypertension, which required administration of carvedilol twice daily with the instruction to hold the medication if the resident's heart rate was less than 60 beats per minute. Clinical record review showed that the medication was administered on three separate occasions in June 2025 when the resident's heart rate was below the specified threshold. The Director of Nursing confirmed that the medication was given outside of the ordered parameters on those dates.