F0684

G

Failure to Administer and Document Medications per Orders and Policy, Resulting in Harm

Carlisle, Pennsylvania Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide medications in accordance with physician orders, professional standards, and facility policy, resulting in missed doses, inaccurate documentation, and lack of timely physician notification. Facility policy required medications to be administered per written orders, documented immediately on the MAR, and for withheld or refused doses to be coded with explanatory notes, with physician notification if two consecutive doses of a vital medication were missed. Policy also required appropriate ordering, receipt, and use of controlled medications, including timely reordering and use of emergency supplies when appropriate. These standards were not followed for three residents.

For one resident with epilepsy and dementia, the physician had ordered lacosamide 100 mg orally every 12 hours. The controlled substance record showed 30 tablets received on December 29 and used beginning January 1, with the last available dose given on January 15 at 8:00 PM. Despite this, the January MAR showed a dose documented as given on the morning of January 16 by an LPN, even though no medication remained; the nurse later stated she had erroneously charted that administration. Subsequent MAR entries for lacosamide on January 16 (PM) and January 17 (AM and PM) were marked as held with notes indicating the drug was on order, on back order, or not available, and progress notes documented repeated calls to the pharmacy. There was no documentation that the physician was notified that four scheduled doses on January 16 and 17 could not be given until after the resident experienced seizure activity late on January 17, which led to transfer to the emergency room. The resident returned without the facility having lacosamide available, experienced another seizure the following morning, and was again sent to the hospital; documentation reflected ongoing uncertainty about when the last doses had actually been administered and that no acute seizure medications were available at the facility at those times.

For a second resident with dementia and anxiety disorder, with orders for buspirone every 8 hours, Tylenol Extra Strength three times daily, and Xanax 0.5 mg every 8 hours, the January MAR showed blank entries for the 2:00 PM doses of all three medications on two separate days. On those same days, the controlled substance record showed the 2:00 PM Xanax doses signed out as administered by nursing staff, but there was no corresponding MAR documentation or progress notes explaining whether the medications were given or held. On another date, the MAR showed a 2:00 PM Xanax dose held with a note that it was not needed, while the controlled substance record showed the same dose signed out as administered, creating conflicting documentation. Later in the month, two scheduled Xanax doses were held due to awaiting pharmacy delivery, and progress notes described difficulty obtaining the ordered dose from the emergency supply and the need for a one-time alternative dose order. The controlled substance record for Xanax showed the prescription filled by the pharmacy the day before, but the receipt verification section was left blank, and the first dose from that package was not documented as given until later that day.

For a third resident with dementia, hypertension, and cough, physician orders included albuterol nebulizer solution every four hours, geri-tussin syrup every four hours, and Protonix 40 mg in the morning. The November MAR showed blank entries for the 4:00 AM doses of albuterol and geri-tussin and the 6:00 AM dose of Protonix on a specific date, with no corresponding progress notes documenting whether these medications were administered, refused, unavailable, or intentionally held. During interviews, the DON stated she expected staff to administer medications as ordered, reorder medications when down to a five-day supply, follow up with the pharmacy when medications were not delivered, notify physicians promptly when medications were unavailable, and complete all MAR and controlled substance documentation, including receipt verification. The survey findings showed that these expectations and facility policies were not met for the three residents, resulting in missed or undocumented doses, conflicting records, and lack of timely physician notification when ordered medications were not available.