Failure to Administer Ordered Medication
Penalty
Summary
Facility staff failed to administer Cyclobenzaprine, an oral muscle relaxant, as ordered by the medical provider for one resident. The resident had multiple diagnoses, including encephalopathy, hemiplegia, hemiparesis, congestive heart failure, epilepsy, and several fractures, and was assessed as cognitively intact. The clinical record included a provider order for Cyclobenzaprine 10 mg by mouth three times daily for muscle spasms. Review of the September 2024 Medication Administration Record (MAR) showed an omission of the medication on a specific date and time, with no documentation that it was given. When interviewed, the Interim Administrator confirmed the medication was not signed off and assumed it was not administered. No additional information regarding the omission was provided to the survey team before the exit conference.