Failure to Administer and Document Psychotropic Medication as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered for one resident. Record review showed that this resident had a lorazepam order changed on 3/14/25 from every hour as needed to a scheduled twice-daily dose due to an increase in behaviors. On the same day, Depakote was ordered twice daily for behaviors and agitation. Review of the March 2026 MAR revealed that lorazepam doses were left blank, indicating they were not given, from the afternoon dose on 3/14/26 through the morning dose on 3/19/26, when the medication was discontinued in the afternoon. In contrast, Depakote was marked as not available only for the afternoon dose on 3/14/26 and then documented as administered as ordered on subsequent days. Progress notes documented multiple reasons for lorazepam not being given, including waiting for medication delivery on 3/16/26 and the prescription not being signed by the provider on 3/17/26 and 3/19/26. Additional progress notes on 3/17/26 at 11:36 AM and on 3/18/26 at 11:53 AM and 7:40 PM stated that lorazepam was given as ordered, but these administrations were not recorded on the MAR. During an interview, the DON explained that if a provider had not signed the medication order, the pharmacy would not release the medication, and acknowledged that the medication should have been given as ordered and that staff should have obtained the provider’s signature. No additional documentation was provided to reconcile the discrepancies between the progress notes and the MAR entries.
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.