F0658

D

Failure to Administer Admission Medications and Use Emergency Supply for New Residents

Saint Peters, Missouri Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were administered as ordered on admission and to follow procedures when medications were not available. For one resident with diagnoses including type 2 diabetes mellitus, pneumonia, and COVID, a stat chest x-ray on 1/13/26 showed pneumonia, and the physician ordered doxycycline 100 mg BID for five days and Augmentin 500/125 mg daily for five days. These orders were entered on the POS and MAR on 1/13/26 at 4:30 P.M., but there was no documentation that staff administered either antibiotic that day. The facility’s emergency medication supply list showed Augmentin 500/125 mg and doxycycline 100 mg were available, yet there was no documentation that staff notified the physician or pharmacy when the medications were not given or if they were not obtained from the emergency supply.

For another resident admitted from the hospital with diagnoses including influenza A with pneumonia, bacterial pneumonia, COPD, acute respiratory failure with hypoxia and hypercapnia, and chronic atrial fibrillation, hospital discharge orders included atorvastatin 80 mg at bedtime, Eliquis 5 mg BID, metoprolol 12.5 mg BID, nystatin suspension QID, and DuoNeb every six hours, with next doses due the evening and bedtime of the admission date. The POS reflected these orders, but the MAR showed staff did not administer the bedtime doses of atorvastatin, Eliquis, or metoprolol, nor the scheduled nystatin doses at 4:00 P.M. and 8:00 P.M., nor the DuoNeb dose at 8:00 P.M. The resident reported not receiving bedtime medications because the facility did not have them. The emergency medication supply list showed Eliquis 5 mg and metoprolol 25 mg were available, but they were not used.

Staff interviews revealed confusion and inaction regarding medication availability and use of the emergency kit. One LPN stated the pharmacy delivered the resident’s medications the following morning, claimed no doses were due the prior night, and said he/she did not have access to the emergency kit, later acknowledging that Eliquis was in the kit and could have been administered. Another LPN stated there was an e-kit for after-hours or new admission medications but was unsure which medications it contained, confirmed the resident did not receive medications because the pharmacy had not yet delivered them, and reported the resident still had not received DuoNeb due to waiting on a nebulizer, despite central supply maintaining medical equipment such as nebulizers. The facility did not provide a policy related to obtaining newly ordered medications from the pharmacy or procedures to follow when medications were not available.