F0760

E

Failure to Administer Scheduled Morning Medications to Multiple Residents

Modesto, California Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors when a contracted RN did not administer any scheduled morning medications to nine sampled residents on 12/26/25. Interviews with facility staff confirmed that the facility’s process required nurses to follow physician orders and administer medications within one hour before or after the scheduled time, and that not doing so created a potential for harm. The Director of Staff Development stated that the RN working that morning did not administer any scheduled morning medications for the nine residents for an unknown reason, and emphasized the importance of following the rights of medication administration, including right dose, right time, and right route. The DON reported being notified that the scheduled morning medications were still in the medication cart and that the RN would not provide an explanation.

In a telephone interview, the RN who worked that morning acknowledged she was responsible for administering medications to the nine residents and stated she was not aware of the facility’s medication administration schedule times, resulting in medications not being administered as ordered. She stated that medications should have been given within one hour before or after the scheduled time and admitted she knew some residents did not receive medications and that she did not address the missing doses or notify the physicians. She acknowledged that it was wrong not to administer medications as scheduled and that there was a potential for adverse side effects for the affected residents when medications were not administered as ordered.

Record review showed that each of the nine residents had multiple ordered medications that were not administered on the morning of 12/26/25, as documented on their Medication Administration Records (MARs) and supported by SBAR notes indicating that morning medications were not given. These residents had significant medical diagnoses including hypertension, diabetes, heart failure, respiratory failure, COPD, atrial fibrillation, kidney failure, sepsis, lupus, necrotizing vasculopathy, and other chronic conditions. The missed medications included antihypertensives, anticoagulants (including Eliquis and aspirin), insulin and other diabetes medications, diuretics, heart failure medications, dementia medications, psychiatric medications, antibiotics, and various supplements and GI medications. SBAR documentation for each resident noted that morning medications were not administered and that residents were assessed later with no adverse effects or complications noted at that time, with recommendations that one-time-a-day medications be given immediately. Review of the facility’s RN job description and medication administration policy confirmed that RNs were required to administer medications according to practitioner orders and that medications were to be administered within 60 minutes of the scheduled time in accordance with written physician orders.

The facility’s policy titled “Medication Administration–General Guidelines” specified that medications are to be administered as prescribed, in accordance with good nursing principles, by authorized personnel who are familiar with the medications, and within 60 minutes of the scheduled time. The policy also stated that the facility must have sufficient staff to allow medication administration without unnecessary interruptions and that medications are to be administered according to the established medication administration schedule. Despite these requirements, the contracted RN on the morning of 12/26/25 did not administer any of the scheduled morning medications for the nine residents, leaving all of their ordered morning doses documented as not given on the MARs. This failure to follow physician orders and facility policy regarding medication administration times constituted the medication error deficiency identified by the surveyors.