F0600

D

Failure to Administer Ordered Medications After Staff–Resident Altercation

Beaver Falls, Pennsylvania Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary medications to a resident as ordered, constituting neglect under the facility’s abuse and neglect policy. The facility’s policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required staff to verify correct medication, dose, route, rate, time, and resident with each administration. The resident involved had an MDS dated 11/26/25 showing diagnoses including a history of falls, diabetes, and hypertension, and a care plan directing that medications be administered per physician orders.

On a specific evening shift, the resident’s January MAR showed that three ordered medications—Seroquel 150 mg, Atorvastatin 10 mg at bedtime, and Lantus Solostar 28 units subcutaneous at bedtime—were not administered. The MAR entries for that date documented these medications as “not administered/resident refused” by an agency RN. However, the following day, the resident reported to nursing staff that he had not received his scheduled medications for that shift. This discrepancy between the MAR documentation and the resident’s report prompted a facility investigation.

During the investigation, multiple staff statements described a verbal altercation between the resident and the agency RN after the RN told the resident he was not permitted in the kitchenette. The RN supervisor reported witnessing the altercation and offering to pass the resident’s medications, but the agency RN refused this assistance. A nurse aide stated that the agency RN asked another nurse or the RN supervisor to provide the medications because the resident was being rude and calling her names, but nursing staff refused to assist. The agency RN stated that after the argument, the resident sat near the nurse station, called her the B-word, then left the unit; she reported she intended to have another nurse administer or witness the medications when the resident returned, but the resident did not return until early morning and did not request medications. In a later interview, the resident stated the nurse was not around between approximately 8 and 9 p.m., that he went to his room, and that she never came to give his medications, and he denied being out of the facility until 1 a.m. These events led surveyors to determine that the facility neglected to provide required goods and services to the resident when his ordered medications were not administered as required.