F0658

E

Medication Administration Not Consistent With Physician Orders and Standards of Practice

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were administered according to physician orders and professional standards for multiple residents. For one resident with hypertension, depression, and non-Alzheimer’s dementia, the care plans required that opiate and antidepressant medications be administered as ordered. During a medication pass observed with an LPN, the nurse removed a lidocaine 4% patch from the resident’s left lower leg just before applying a new patch, despite the Medication Administration Record (MAR) indicating the previous patch had been removed the prior evening. The physician’s order for the lidocaine patch specified application to the knee once daily for pain but did not include application and removal times, and there was no evidence of a physician order specifying the schedule that had been transcribed on the MAR. In the same observation, the LPN administered a 50 mg sertraline tablet even though the current physician order and MAR required 100 mg once daily. A CMA later stated that the resident’s dose had been increased from 50 mg to 100 mg, that a new 100 mg bubble pack had recently arrived, and that she had given two 50 mg tablets the previous day because she had not yet seen the new 100 mg pack.

For another resident with hypertension, anxiety disorder, and depression, the care plan directed that opiate analgesics be administered per orders. The physician ordered a lidocaine 4% patch to be applied to the ankle once daily for pain, but the order did not specify when to apply or remove the patch. The MAR transcribed the order as application in the morning without any removal schedule. During an observed medication pass, an LPN removed an existing lidocaine patch from the resident’s right ankle and immediately applied a new patch to the same site, with no documented or ordered time frame for how long the prior patch had been in place. A third resident with hypertension and a UTI had a physician order for a lidocaine 4% patch to the right shoulder in the morning for pain, again without a specified removal time. The MAR showed administration of the patch, but no removal schedule was transcribed. During an observed medication pass, an RN removed a lidocaine patch from the resident’s right shoulder and applied a new patch below the right shoulder, again without any documented or ordered removal interval.

A fourth resident with hypertension, depression, PTSD, morbid obesity, and edema was receiving diuretic therapy with furosemide. The care plan required medications to be administered as ordered, with monitoring for side effects and attention to dosing and potential need for modification. The physician order summary showed furosemide 20 mg by mouth twice daily for edema, with no specific administration times. The MAR, however, listed the doses at 8:00 AM and 12:00 PM, approximately four hours apart, without any corresponding physician order specifying those times. The MAR documented administration at 8:00 AM on one survey day, and an LPN was observed administering another 20 mg dose at 11:28 AM, about three and a half hours after the prior dose. Nursing staff interviewed stated that twice-daily furosemide is usually given in the morning and late afternoon or evening, and one RN stated that giving it at 8:00 AM and 12:00 PM could cause excessive urination and increase the risk of dehydration. The provider later stated that standard practice for twice-daily furosemide is morning and evening and that he does not advise morning and noon dosing, while the pharmacist stated that furosemide is usually given 6–8 hours apart and that administration times are normally set by the facility unless specified by the provider. Facility policies required medications to be administered only upon written order, with orders consistent with safe and effective order writing, and established that BID medications are to be given according to a routine schedule unless a physician specifies otherwise or an alternate schedule is documented, but the BID furosemide schedule for this resident had been set and followed without a corresponding physician instruction in the record.