F0842

D

Failure to Accurately Document and Administer Ordered Medications

Philadelphia, Pennsylvania Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure complete and accurate medication administration documentation in the medical records for two residents, contrary to its own policies and professional standards. Facility policies required licensed nursing staff to administer medications as ordered by the physician, observe residents consuming medications, and record administration on the medication administration record (MAR) as part of an accurate, complete, and timely medical record. For one resident with asthma, hypertension, depression, hypoxia, diabetes mellitus, and severe stenosis with myelomalacia, clinical record review showed multiple instances where ordered medications and treatments were not documented as administered. These included missed 5:00 p.m. doses of formoterol fumarate nebulizer solution for asthma on several dates, missed 5:00 p.m. and 9:00 a.m. doses of pregabalin for a cerebral vascular accident diagnosis, and failure to obtain and record blood glucose readings with corresponding insulin lispro injections for diabetes at specified times.

For the same resident, the MAR also showed that topical 1% gel ordered for bilateral knee pain was not applied at 5:00 p.m. on multiple dates as ordered. For a second resident with anxiety disorder, end stage renal disease, sepsis, and spina bifida, the MAR indicated that although Ativan 2 mg was documented as given at certain times, there were multiple occasions when the ordered 2 mg doses every 12 hours were documented as omitted and not administered as prescribed. An interview with the assistant director of nursing confirmed the lack of medical record documentation indicating that these residents received their ordered medications and treatments in accordance with professional standards of nursing practice and the facility’s medical record documentation policy.