Failure to Administer and Document Ordered Medications and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and treatments were administered and documented in accordance with prescriber orders and facility policy, resulting in multiple omissions for two residents. The facility’s medication administration policy dated January 2023 required that medications be administered per written prescriber orders and that the individual administering the medication immediately record the administration on the MAR. During review of October and November 2025 MARs and TARs, surveyors identified numerous blank entries, which the Director of Resident Services confirmed meant the medications or treatments were not done or not documented, and stated those areas should not be blank. For one resident with metastatic cancer, chronic respiratory failure, hypertension, reduced mobility, weakness, and severe cognitive impairment, the October and November 2025 MAR/TAR showed multiple omitted treatments and monitoring tasks. These included missed catheter care and failure to document urinary output on several shifts, missed weekly skin observations, and omitted application of Triad barrier cream and other barrier creams to the buttocks and posterior thighs for skin breakdown and redness. Additional omissions included ordered bladder scans every six hours with straight catheterization for post-void residuals greater than 350 cc at several scheduled times, and failure to ensure bilateral heel boots were in place while the resident was in bed. For another resident with metabolic encephalopathy, a UTI, and severely impaired cognition, the October and November 2025 MAR/TAR also showed omitted medications and treatments. These included missed doses of levothyroxine and acetaminophen at scheduled administration times, as well as failure to complete ordered orthostatic blood pressure measurements and weekly weights. The records further showed omissions in applying barrier cream to the coccyx every shift and as needed for redness, and failure to elevate the head of the bed every shift as ordered to alleviate or prevent shortness of breath while lying flat. The Director of Resident Services confirmed that the blank MAR/TAR entries for these residents indicated the orders were not carried out or not documented.
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