Failure to Follow Medication Administration Orders and Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to the physician’s orders and manufacturer’s instructions for one resident with Parkinson’s disease, dementia, and weakness. The resident was severely cognitively impaired and required substantial/maximal assistance with eating and oral hygiene. A physician’s order dated 12/25/2025 specified that the resident’s medications were to be given whole in applesauce. Active medication orders included delayed-release aspirin 81 mg once daily, carbidopa-levodopa 25-100 mg three times daily, and delayed-release bisacodyl 5 mg at bedtime. The January 2026 MAR did not include instructions to administer medications whole in applesauce. Manufacturer instructions for delayed-release aspirin and bisacodyl stated these medications must not be chewed, crushed, or broken because crushing destroys the enteric coating and may cause severe stomach irritation. Nursing documentation and interviews showed inconsistent and inappropriate medication administration practices. Nursing notes by one nurse on multiple dates in early January documented that the resident tolerated medications given whole in applesauce, while other notes by the same nurse and another nurse documented that medications were crushed in applesauce. One nurse documented crushing medications due to the resident’s “slow alertness,” and in an interview admitted she crushed all of the resident’s medications on a shift despite knowing the order required them to be given whole in applesauce and acknowledging that some were extended-release. Another nurse stated she crushed the resident’s medications on days when the resident was “slow” to swallow, even though the resident was not having difficulty swallowing, did not notify the provider, and did not document a change in condition, believing she could use nursing discretion. The NP stated that being slow to take medications was not an indication to crush them and that she had not received any communication about swallowing difficulties. The DON stated nurses were expected to administer medications as ordered and to notify the physician or request a swallowing evaluation if it was unsafe for a resident to take medications whole.
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