F0684

E

Failure to Assess Injury Complaint and Ensure Availability of Ordered Medications

Philadelphia, Pennsylvania Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in assessment and medication administration for three residents. One resident with epilepsy, depression, PTSD, adjustment disorder, anxiety, hypertension, and diabetes reported that a drawer or dresser fell on their right shoulder while they were sitting on the bed and that their arm hurt. The clinical record contained no documentation that this alleged event occurred, no nursing assessment of the shoulder/arm area over time, and no documentation of vital signs or physician notification related to the incident. A licensed nurse confirmed that the resident had reported that a dresser fell on their shoulder and stated that the manager on duty, the Human Resources Manager, instructed him not to document anything about the event in the clinical record.

The deficiency also includes failures to administer medications as ordered for two other residents. One resident with kidney failure, osteoporosis, psychosis, and PTSD had a physician’s order for 1–2 mg of haloperidol to be given in the morning for psychosis and schizophrenia; during a medication pass, the LPN could not locate the haloperidol on the cart or in the medication room and reported that the medication could not be administered because the resident had no more doses left and it needed to be reordered from the pharmacy. Another resident with lumbago with sciatica, hypertension, and epilepsy had a physician’s order for 15 mg oxycodone to be given by mouth every 10 hours for pain related to lumbago with sciatica; during a medication pass, the LPN informed the resident, who stated they were in a lot of pain and needed their pain medication, that the oxycodone was not available because it had not been delivered by the pharmacy and a prescription from the physician was needed.