Failure to Ensure Accurate Medication Orders and Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate medication orders and administration according to physician orders for one cognitively intact resident with multiple chronic conditions, including rheumatoid arthritis, pain, diabetes, atrial fibrillation, fibromyalgia, and osteoporosis. The resident’s Medication Administration Record (MAR) for December showed that Alendronate Sodium 70 mg, ordered once weekly on Sunday at 6:00 AM for osteoporosis, was not documented as administered on the scheduled date, and there was no progress note explaining the omission or indicating that the physician was notified. Arava (Leflunomide) 20 mg, ordered once daily in the morning for inflammation, was not documented as administered on a scheduled morning dose, with a correlating progress note simply stating “n/a for Arava” and no documentation of physician notification. The MAR also reflected an order for Liraglutide 1.2 mg SC daily at 8:00 AM for diabetes that was not documented as administered on two separate days. Progress notes for those dates recorded “n/a for Liraglutide” and “Not given due to wrong order,” but did not document that the physician had been notified of the missed doses or the concern about the order. In a subsequent interview, the prescribing physician clarified that the intended Liraglutide dosing should have started at 0.6 mg daily for one week, then increased to 1.2 mg daily, and possibly to 1.8 mg daily, indicating the order in the record did not reflect the intended titration. Additionally, Cyclobenzaprine 10 mg, ordered three times daily for muscle spasm relief, was not documented as administered for one scheduled evening dose, with a progress note stating the medication was “on order” and again no documentation that the physician had been notified. The DON reported that medications arriving after late admissions might not be available until the next day and that if medications were unavailable, the physician should be notified and the notification documented, and also noted that Liraglutide was a pharmacy interchange for Ozempic.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.