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F0658
D

Failure to Follow Professional Standards in Medication Administration and Documentation

Woodstock, Virginia Survey Completed on 09-26-2025

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

Facility staff failed to follow professional standards of practice in the administration and documentation of medications for two residents. For one resident, staff administered tramadol and oxycodone without current physician orders in place. The medications were given based on the presence of medication cards in the medication cart, and not on active orders in the electronic system. Subsequently, backdated orders were entered into the system several days later, with staff indicating that nursing management had claimed to have obtained physician approval, though the physician did not recall authorizing these orders. Facility policy required that physician orders be appropriately and timely documented and confirmed by the ordering physician, which was not followed in this instance. For another resident, staff failed to follow professional standards in the administration of Carvedilol and Entresto, both prescribed for heart failure and related conditions. On a specific date, the electronic medication administration record (eMAR) indicated that these medications were not administered because the resident was sleeping. There was no evidence of additional attempts to administer the medications later, nor was there documentation of physician notification regarding the missed doses. The physician orders did not include instructions to hold the medications if the resident was sleeping, and the nurse interviewed stated that important medications should be administered unless there was a specific order to hold them, and that the physician should be notified if medications are held. Both incidents were confirmed through staff interviews, clinical record reviews, and facility policy review. The failures included administering medications without proper authorization and not ensuring critical medications were administered or that the physician was notified when doses were missed. These actions did not meet professional standards of quality as required by facility policy and nursing best practices.

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