Multiple Residents Did Not Receive Ordered Evening Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders, resulting in multiple omitted doses for three residents during one evening medication pass. The facility’s Medication Error Policy dated 2/2/26 requires that medications be administered as ordered and that any medication errors be reported to the physician, documented in the medical record, and reported to the appropriate supervisor. A Resident/Family Complaint Form dated 1/26/26 documents that one resident (R13) reported not receiving her evening medications on 1/23/26. During an interview on 2/5/26 at 11:48 a.m., the DON (V2) stated that residents on the Northeast Hall did not receive their evening medications on 1/23/26 and acknowledged that R13 filed a grievance about the missed medications. Record review of the January 2026 Medication Administration Records (MARs) confirmed that multiple ordered medications were not administered on the evening of 1/23/26. For R13, the MAR showed missed doses of Famotidine 20 mg, Fluticasone Propionate nasal spray, Potassium Chloride 20 mEq, Baclofen 10 mg, Diclofenac Sodium Gel 1%, and Gabapentin 1200 mg. For R14, the MAR showed missed doses of Atorvastatin 40 mg, Carvedilol 25 mg, Clonidine 0.1 mg, Doxazosin 4 mg, and Eliquis 2.5 mg. For R15, the MAR showed missed doses of Fluticasone Furoate inhalation 200-25 mcg and Rosuvastatin 5 mg. During the same 2/5/26 interview, the DON confirmed that nurses are required to administer medications per physician orders and to notify the physician and nurse supervisor when medications are not administered.
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