F0726

D

Failure to Obtain Timely MD Verification and Administer Admission Medications

Los Angeles, California Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely physician verification and administration of admission medications for a newly admitted resident. The resident was admitted with diagnoses including DM, hypertension, gout, GERD, hypothyroidism, hyperlipidemia, glaucoma, bipolar disorder, schizophrenia, and depression. The resident’s H&P indicated a lack of capacity to understand and make decisions, while the MDS documented that the resident could understand and be understood and required varying levels of assistance from supervision to maximal assistance for ADLs and mobility. Telephone orders dated the early morning after admission listed multiple medications, including antihypertensives, insulin (both glargine and sliding scale regular insulin), psychotropic medications, and other chronic disease medications.

Record review and staff interviews showed that the resident’s admission date and time were documented, but the resident did not receive night medications due on the evening of admission, including carvedilol, insulin glargine, and trazodone, because the medication orders were not verified by the prescribing physician. The LVN interviewed stated that the resident’s medication administration history showed that all 9 a.m. medications the following day were not given until 12:21 p.m., over three hours late. These medications included aripiprazole, famotidine, sliding scale insulin, lisinopril, olanzapine, quetiapine, and trazodone. The LVN explained that the delay and missed doses were related to the lack of physician verification of the admission orders.

Further interviews revealed that the admitting nurse did not enter any physician orders at the time of admission and could not recall why the admission orders were not entered. Another LVN stated she did not make a follow-up call to the physician because physicians do not answer facility calls on night shift and that she had been told by an administrator to enter physician orders without calling the physician, as night shift nurses enter orders without contacting MDs. The medication list used for the physician orders was taken from the resident’s hospital discharge paperwork. The attending physician later stated she had not given admission orders for the resident on the date of admission and emphasized the importance of MD review of admission orders to prevent medication errors, duplicate drugs, or contraindicated medications.