F0755

E

Failure to Follow Medication Orders and Complete MAR Documentation for Two Residents

Lancaster, California Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for two residents. For one resident with osteomyelitis, diabetes mellitus, and hypertensive heart disease with heart failure, the physician’s order dated 11/11/2025 directed metoprolol succinate 50 mg by mouth daily for hypertension, to be held if systolic blood pressure (SBP) was less than 110 mmHg or heart rate less than 60 beats per minute. The January 2026 MAR showed that on 1/9/2026 at 9 a.m., LVN 4 administered metoprolol when the resident’s blood pressure was 104/76 mmHg. In interviews, LVN 1, the DSD, and the DON each stated that the metoprolol should have been held and that the nurse should have checked the physician order prior to administration.

The same resident also had orders for pantoprazole 40 mg by mouth in the morning on an empty stomach for GERD and insulin lispro per sliding scale subcutaneously before meals for diabetes. Review of the January 2026 MAR showed that on 1/8/2026 at 6:30 a.m., both pantoprazole and insulin lispro entries were blank. The QAN confirmed that the pantoprazole and insulin lispro were left blank on the MAR and that there was no recorded blood sugar at the time the insulin was due; the next recorded blood sugar at 8:10 a.m. was 221 mg/dl. The DON stated that the resident could experience hyperglycemia and GERD because LVN 3 did not administer the pantoprazole and insulin.

A second resident, admitted with metabolic encephalopathy, unspecified hereditary and idiopathic neuropathy, and unspecified hypothyroid, had physician orders dated 8/22/2025 for famotidine 20 mg by mouth in the morning before meals for GERD, gabapentin 300 mg by mouth in the morning for neuropathy, and levothyroxine 50 mcg by mouth in the morning before breakfast for hypothyroidism. The January 2026 MAR showed that on 1/8/2026 at 6 a.m., gabapentin and levothyroxine entries were blank, and at 6:30 a.m., famotidine was blank. The QAN and DON both stated that blank MAR entries indicated the medications were not administered and that the resident could experience GERD, increased neuropathic pain, and uncontrolled hypothyroidism. The facility’s “Administering Medications” policy dated 5/2024 required medications to be administered safely, timely, and as prescribed, within one hour of the prescribed time, and in accordance with prescriber orders, including checking vital signs when necessary.