F0760

D

Failure to Administer Ordered Insulin and Cardiac Medications as Prescribed

Sarver, Pennsylvania Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The facility failed to ensure residents were free from significant medication errors when ordered medications were not administered as prescribed and when medications were unavailable. For one resident with anxiety, depression, and diabetes, a physician’s order directed administration of Insulin Lispro via sliding scale before meals and at bedtime. A progress note documented that the resident did not receive the ordered bedtime Insulin Lispro because the nurse was unable to log into the computer and determined it was too close to the next dose to administer. For a second resident with similar diagnoses and an order for Insulin Lispro via sliding scale before meals and at bedtime, a progress note documented that the resident did not receive the ordered bedtime insulin dose because the resident was sleeping.

A third resident with heart failure, hypertension, and atrial fibrillation had a physician’s order for Carvedilol 6.25 mg by mouth twice daily for ventricular tachycardia. The January MAR showed a nurse entry to “see nurse’s note” for an evening dose, and a subsequent progress note documented that the medication was not available in the medication cart and needed to be reordered. In a written statement, the RN reported that multiple active medications were not available in the cart during the scheduled evening medication pass and that they were not informed that an emergency medication kit was available in the facility. The RN also reported that the eMAR did not display all medications due during the scheduled pass, and that additional missed medications were only identified after a later review. An LPN interview confirmed that medications are to be given within one hour before or after the scheduled time and that residents should be awakened to receive medications.