Failure to Administer Medications as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including schizoaffective disorder, hypertension, dementia without behavioral disturbances, and bipolar disorder did not receive prescribed medications as ordered. The resident, who had severely impaired cognition and required supervision with activities of daily living, was admitted to the facility and had physician orders for lorazepam 1 mg and trazodone 50 mg to be administered at bedtime. Review of the Medication Administration Record (MAR) showed that lorazepam was not administered from 08/08/25 through 08/10/25, and trazodone was not administered on 08/08/25 and 08/09/25, as ordered by the physician. The Director of Nursing confirmed that there was no documentation to support that the resident received these medications on the specified dates. Facility policy requires that medications be administered in a safe and timely manner, and as prescribed. The failure to administer these medications as ordered was confirmed through medical record review, staff interview, and policy review.