F0755

E

Failure to Administer Medications Timely and as Ordered for Multiple Residents

Racine, Wisconsin Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications in accordance with physician orders and facility policy, including timeliness standards, for multiple residents. One resident with generalized anxiety disorder, severe cognitive impairment (BIMS score of 5), anxiety, and depression had a scheduled order for hydroxyzine 10 mg three times daily beginning mid-September. The MAR showed numerous instances where the hydroxyzine doses were administered outside the facility’s stated 1-hour before/after window, including morning, noon, and afternoon doses given significantly late on multiple days. The same resident’s hydroxyzine was also discontinued on one date and not restarted until two days later, resulting in missed doses, and when restarted with a new three-times-daily schedule, there were additional late administrations and at least one dose left blank, indicating it was not administered.

The same resident’s hydroxyzine order was changed by a nurse practitioner from scheduled to PRN, and a subsequent progress note documented that an LPN contacted the practitioner to clarify the order after a family member reported what medication the resident was supposed to be receiving. At that time, the LPN noted there was no active order in the record, and a verbal order was given to restart the hydroxyzine. The facility’s MARs for September and October continued to show repeated late administrations of the hydroxyzine outside the scheduled time frames, including multiple morning doses given more than an hour after the scheduled time and some evening doses given early or late. The unit manager later stated she did not know who reviews provider assessments after visits, was unaware of who uploads them into the charts, and acknowledged that no one was currently reviewing them.

Additional deficiencies were identified for other residents. One nurse administered multiple 8:00 AM medications, including atorvastatin, vitamin D3, sertraline, acetaminophen, propranolol, potassium ER, and apixaban, at 11:01 AM, two hours past the allowable window, and reported being pulled to other units to administer IV medications, with other residents’ 8:00 AM medications still pending. Another nurse administered 7:00 AM medications, including tramadol and omeprazole, after the allowed time window. A resident receiving IV cefepime 2 g every eight hours for a catheter-associated UTI had three initial doses not given because the medication had not arrived from the pharmacy, one dose documented as administered five and a half hours early, and several later doses not signed out at all. The DON later stated that a night-shift RN had come in early to hang IV medications and thought they had been signed out, but the MAR still lacked signatures for those doses when re-reviewed. The facility’s written policy required medications to be administered per orders within a 60-minute before/after window, which was not followed in these instances.