Failure to Administer Medications, Supplements, and Treatments as Ordered
Penalty
Summary
Facility staff failed to administer medications, treatments, and supplements as ordered for two residents. For one resident with dementia, Donepezil 5 mg was not administered as ordered on the evening of 9/11/25, despite the medication being available in the Omnicell system. The Director of Nursing confirmed that the medication was not given as prescribed by the physician. Another resident, admitted with malnutrition, did not receive a recommended house supplement shake in a timely manner. Although the Registered Dietitian recommended the supplement and the Nurse Practitioner agreed, the supplement was not ordered until three days later and not administered until four days after the recommendation. Additionally, this resident did not receive ordered wound treatments for a left foot wound on several documented shifts, with no evidence of administration in the treatment record. The Director of Nursing confirmed the lack of documentation for these missed treatments.