Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents received necessary care and treatment as ordered, specifically related to medication administration. For one resident with diagnoses including congestive heart failure, diabetes, and acute kidney failure, a physician ordered an additional dose of furosemide for worsening symptoms, but the dose was not administered. The medication administration record (MAR) showed the dose was scheduled but left blank, and a nursing note indicated it was considered a duplicate order, resulting in the resident only receiving the original dose. No further explanation was provided by facility leadership. Two other residents with infections also did not receive medications as ordered. One resident with acute polynephritis and diabetes did not have two scheduled doses of cephalexin signed out as given, with no documentation explaining the omission. Another resident with muscle weakness, encephalopathy, and acute cystitis missed three doses of cephalexin due to pharmacy time changes and discontinuation of the original order, as confirmed by the nurse consultant. These failures were identified through record review and staff interviews.