Failure to Administer and Document Medications as Ordered
Penalty
Summary
Surveyors identified a failure to administer medications as ordered by the physician for one resident. The resident was admitted with chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and chronic respiratory failure, and an annual MDS showed the resident was cognitively intact and largely independent with activities such as eating, bed mobility, toileting hygiene, and transfers with set-up assistance. Physician orders included metformin 500 mg twice daily, ferrous sulfate 325 mg daily, loratadine 10 mg daily, Theragran-M daily, montelukast sodium 10 mg daily, ibuprofen 800 mg three times daily, methocarbamol 750 mg three times daily, and Os-Cal 500-150 mg daily. Review of the November 2025 MAR for this resident showed no documentation that medications were administered as ordered on multiple specific dates, and the January 2026 MAR also lacked documentation that medications were given as ordered on two additional dates. The resident reported not receiving medications at times, and the Administrator confirmed that the medical record did not contain documentation to support that medications were administered as ordered on the identified dates. Facility policy on administering medications stated that medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including required time frames, which was not followed in this case.
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