Failure to Administer Prescribed Medications to Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a newly admitted resident with schizophrenia and multiple comorbidities received prescribed medications according to physician orders and facility policy. The resident was admitted with active diagnoses including schizophrenia, anxiety disorder, moderate intellectual disabilities, thyroid disorder, and hyponatremia, and had a hospital discharge medication list that included medications for extrapyramidal and movement disorders, mood stabilization, antipsychotic treatment, thyroid replacement, hypertension, hyponatremia, sleep, and a vitamin. The admission MDS showed the resident was cognitively intact, and the care plan initiated the day after admission included interventions to administer anxiety and schizophrenia medications, educate the resident about toxic symptoms, and monitor for reactions and side effects, as well as interventions related to elopement risk and placement on a secured unit. On the day following admission, the Medication Administration Record documented that 15 scheduled doses of various medications were not administered. For multiple medications, including mood stabilizers, antipsychotics, thyroid medication, hypertension medication, an NSAID, a vitamin, and a medication for extrapyramidal and movement disorders, the MAR entries showed reasons such as “drug refused,” “meds unavailable,” or “drug not available.” Only one dose of a medication for hyponatremia at 4:00 PM on that day was documented as administered from the time of admission until the resident eloped the next day. Nursing staff interviews revealed that one LPN stated the resident did not receive medications on the day shift because they had not yet been delivered from the pharmacy, and another LPN stated that medications were delivered after the nighttime medication pass and was unsure whether any of the resident’s medications could have been obtained from the Pyxis. Facility records and leadership interviews further clarified the sequence of events. The drug manifest log showed that several of the resident’s medications, including those for hypertension, schizophrenia, extrapyramidal and movement disorders, mood stabilization, antipsychotic treatment, thyroid replacement, and an NSAID, were signed as received from the pharmacy at 8:40 PM on the day after admission. The DON confirmed that the omitted doses and rationales documented on the MAR were accurate and reiterated that facility policy required medications to be administered within one hour before or after the scheduled time. The Administrator confirmed that only one dose of any prescribed medication was administered from admission until the resident’s elopement and stated that certain psychotropic and anxiety medications were available in the Pyxis, but she could not determine why the LPN did not access them or why medications were not administered after pharmacy delivery.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.