Failure to Administer Ordered Morning Medications and Notify Physician
Penalty
Summary
A resident with a diagnosis of pulmonary embolism and no cognitive impairment, as evidenced by a BIMS score of 15, did not receive ordered morning medications on February 20, 2026. Physician orders for that morning included Eliquis 5 mg and Hydrochlorothiazide 25 mg. Review of the Medication Administration Record (MAR) for that date showed that the morning medications were not administered by the assigned LVN. The resident reported during interview that she did not receive her 9:00 a.m. medications on that date and stated she did not experience any adverse side effects from missing them. Record review revealed no progress note or other documentation explaining why the medications were not given and no indication that the physician was notified of the missed doses. The resident’s care plans directed staff to administer Hydrochlorothiazide and anticoagulant medications, including Eliquis, as ordered. The DON confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time and that, when medications are not administered, the nurse must notify the physician and document the reason. The LVN acknowledged being the medication nurse that morning, confirmed the medications were not administered, could not recall the reason, and verified that the physician was not notified and no progress note was entered, despite facility policy requiring both actions when medications are held.
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