Failure to Administer Ordered Respiratory and Anticoagulant Medications
Penalty
Summary
Facility staff failed to administer medications according to physician orders for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and had admission orders dated 12/26/25 for Combivent 1 puff BID, Symbicort 2 puffs BID, and apixaban 5 mg BID. Review of the December 2025 MAR showed that the evening doses of Combivent, Symbicort, and apixaban were not administered on 12/26/25 as ordered. In an interview on 2/27/26 at 9:39 AM, the Interim DNS confirmed that these medications were not given as ordered on that date. This failure to administer the ordered evening doses of respiratory inhalers and an anticoagulant placed residents at risk for not receiving medications as ordered and potential side effects, as identified through interview and record review.
