F0658

E

Failure to Follow Professional Standards in Medication Availability, Administration, and Monitoring

Albuquerque, New Mexico Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves failures to meet professional standards of quality in medication management and monitoring for two residents. For one resident with an order dated 12/16/25 for Jardiance 10 mg orally once daily to control blood sugar levels, the MAR from 01/29/26 through 02/06/26 showed the medication as administered on multiple dates (01/30/26, 01/31/26, and 02/04/26 through 02/06/26) despite the medication not being available. A CMA stated that the last actual dose was given on 01/28/26 and confirmed that she documented the medication as given on 01/30/26, 01/31/26, and 02/06/26 even though it was not available and not administered. An RN and an LPN both confirmed that the Jardiance had not been available since late January and that the resident had not been receiving it since that time. The LPN further reported that she had been checking the resident’s blood sugars without a physician’s order, was not documenting those blood sugar results in the chart, and was using the information only for her own reference.

For another resident admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura, multiple warfarin dose changes were ordered over January 2026 for treatment of cerebral infarction affecting the left dominant side. Review of the January MAR showed that this resident missed warfarin doses on 01/18/26, 01/19/26, and 01/21/26. The DON confirmed that these warfarin doses were missed, acknowledged that warfarin is a high-risk medication that should be given as ordered, and stated she had not been aware that any doses were missed. The DON also stated she expects nurses to notify her and the pharmacy when medications are not available.