F0658

D

Failure to Administer and Manage Medications in Accordance With Professional Standards

Saint Louis, Missouri Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in medication administration and communication that did not meet professional standards of quality. One resident with ESRD on hemodialysis, CHF, hypertension, atrial fibrillation, and other comorbidities had numerous 8:00 A.M. medications, including cardiac, anticoagulant, renal, and vitamin therapies, documented as not given on multiple days because the resident was sleeping. The electronic MAR showed that on ten separate days in January, eight of eight scheduled 8:00 A.M. medications were not administered, and a weekly vitamin D dose was also missed on two of three scheduled Wednesdays, all coded as the resident sleeping. The CMT who typically passed these medications stated the resident preferred to sleep until around noon and did not want 8:00 A.M. medications, but also stated they had not informed the DON or the physician, had not asked the resident about changing medication times, and had only told a nurse that the resident was not taking the morning medications. The nurse who checked the resident’s blood glucose and administered insulin around 8:00 A.M. reported not being aware of the missed 8:00 A.M. medications and indicated that, if informed, they would have attempted to administer the medications or discuss alternate times with the resident.

Another deficiency involved a cognitively intact resident with non‑Alzheimer’s dementia, anxiety, depression, and bipolar disorder who had new orders for Azithromycin for pneumonia and was also prescribed amphetamine‑dextroamphetamine and Valium. A chest x‑ray impression showed focal pneumonia, and a physician order for Azithromycin was obtained that evening. The MAR showed the first Azithromycin dose was not administered until the following day at midday, approximately 15 hours after the order, despite Azithromycin being stocked in the facility’s E‑Kit. The resident reported not feeling well due to pneumonia and stated staff told them the antibiotic had not yet been received. The same resident’s MAR and progress notes documented that amphetamine‑dextroamphetamine and Valium doses were repeatedly not given over several days because the medications were on order or a new prescription was needed. Nursing notes repeatedly indicated the medications were on order or awaiting pharmacy delivery, and that a new script was needed, but one LPN acknowledged not contacting the pharmacy or physician personally and assumed another nurse had done so. Pharmacy records showed that new prescriptions were not received until several days after the medications began running out, and that delivery occurred only after those prescriptions were obtained.

A third deficiency involved a newly admitted resident with C‑diff who had a hospital order for Vancomycin 125 mg daily for four days. The facility MAR contained an order for Vancomycin at 6:00 A.M. for four days, but staff documented code 9 (other/see progress notes) for the first two scheduled doses. The progress notes contained no explanation for the missed dose on the first day and documented on the second day that Vancomycin was pending delivery. A pharmacy representative reported that four doses of Vancomycin were delivered to the facility late morning on the first day, but the first dose was not administered until three days after delivery. The DON stated that when medications are delivered, the receiving nurse is responsible for ensuring medications for residents on other halls are promptly distributed, and that if Vancomycin was delivered that morning, she would have expected it to be administered that day. Across these three residents, the survey identified failures to administer ordered medications as scheduled, to use the E‑Kit for timely initiation of antibiotics, to prevent medications from running out by timely reordering and obtaining new prescriptions, and to document and communicate medication refusals and omissions in accordance with facility policy.