F0684

D

Failure to Follow Medication Orders and Arrange Specialist Consultation

Goshen, Indiana Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for medication administration for one resident and to schedule a specialized physician appointment for another resident. For Resident C, who had diagnoses including exocrine pancreatic insufficiency, cerebral palsy, and type 2 diabetes mellitus and was cognitively intact, hospital discharge instructions ordered pancrelipase (Creon) 36,000 units three times daily with meals and snacks. A physician’s order dated 8/29/2025 directed Creon 36,000–114,000 units one capsule three times daily for exocrine pancreatic insufficiency, but the MAR for late August and early September showed the medication was administered at 6:00 A.M., 2:00 P.M., and 6:00 P.M., which were outside the facility’s scheduled mealtimes. The MAR also showed multiple missed doses on specific dates and times, with no evidence that the physician or nurse practitioner was notified of these missed administrations. A care plan conference note documented that the family had concerns about ensuring the resident received medications before every meal. Additionally, a physician’s order for metoprolol succinate ER 25 mg daily included parameters to hold the medication for systolic blood pressure less than 100 mmHg and heart rate less than 60 bpm, yet the MAR showed the medication was administered on two dates when the resident’s heart rate was below 60 bpm.

For Resident E, who had diagnoses including trigeminal neuralgia and multiple sclerosis and was cognitively intact, the facility failed to ensure a neurological consultation was scheduled as ordered. A physician’s order dated 8/10/2025 directed that a neurological consultation be scheduled. The resident reported having asked staff for over two months to make an appointment with her neurologist due to new symptoms related to multiple sclerosis, and she stated the facility would not make the appointment. A grievance form submitted by the resident on 10/9/2025 requested an appointment with a neurologist and noted a previous request without follow-up; the grievance response stated an appointment had been made, but there was no evidence an appointment was actually scheduled. A nurse practitioner’s note documented that the resident was experiencing uncontrollable trigeminal neuralgia, was screaming out in pain especially in the evenings, had requested to return to her neurologist, and that a referral had already been ordered and the facility was working on setting up the appointment. The transportation director later reported that all outside appointments were to be scheduled through her, that she had not transported this resident to any appointments, and that she had not scheduled any appointments for the resident.