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F0684
D

Failure to Adhere to Physician's Orders for Acetaminophen Administration

Ligonier, Pennsylvania Survey Completed on 09-05-2025

Penalty

No penalty information released
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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

A review of clinical records and staff interviews revealed that the facility failed to follow physician's orders for one resident. The physician had ordered that the resident receive 1000 mg of Acetaminophen by mouth three times daily for pain, with an additional order for 650 mg of Acetaminophen by mouth every 4 hours as needed for pain, not to exceed a total of 3,000 mg in a 24-hour period. Examination of the Medication Administration Record (MAR) for August and September 2025 showed that the resident was administered 3,650 mg of Acetaminophen on two separate days, exceeding the prescribed maximum daily dosage. The DON confirmed that the resident's Acetaminophen dose surpassed the 24-hour limit on the specified dates.

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