Failure to Ensure Pharmacy Supplied Correct Singulair Dose per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its contracted pharmacy provided medications in accordance with the physician’s order for one resident. Facility policy on “Medication Ordering and Receiving from Pharmacy” dated 9/22/25 states that medications are to be administered in an organized and safe manner, including pouring the correct number of tablets or capsules into the medication cup and administering them to the resident. Resident R1’s admission record showed admission on an unspecified date, and the MDS dated 1/10/26 documented diagnoses including diabetes, heart failure, and depression. A physician’s order dated 1/25/26 directed that Singulair 10 mg be given as two tablets every day. During an interview on 2/25/26 at 11:45 a.m., the resident reported that he should be receiving two Singulair 10 mg tablets daily but had only been receiving one tablet. On 2/26/26 at 11:20 a.m., observation of the resident’s medication with Clinical Consultant Employee E9 showed that the pharmacy was supplying Singulair 10 mg in a quantity of one tablet to be administered. In a phone interview at 11:41 a.m. the same day, Pharmacist Employee E10 confirmed that the resident had been receiving only one 10 mg tablet and acknowledged that the pharmacy cycle order was incorrect. Later that day at 3:00 p.m., Clinical Consultant Employee E9 confirmed that the facility failed to ensure the pharmacy provided medications timely and correctly for this resident, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.