F0684

E

Untimely Medication Administration and Poor Wound/Dressing Management

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

Surveyors identified that medications were not administered according to physician orders, resident preferences, and facility policy for multiple residents. During a confidential resident council interview with eight residents, five reported concerns about delayed medication administration, including the absence of a nurse on their wing until midnight and not receiving scheduled morning medications such as a pain patch due between 9:00 AM and 10:00 AM. At the time of the interview, three additional residents also reported they had not yet received their 9:00 AM medications. Review of Medication Administration Records (MARs) on 3/24/26 at 12:40 PM showed that several residents had no documentation of their scheduled 9:00 AM medications or treatments being administered, and there were no progress notes or physician notifications regarding missed or late doses.

Record review for one resident with diagnoses including atrial fibrillation, congestive heart failure, diabetes, and chronic kidney disease showed multiple daily medications such as Eliquis, furosemide, lisinopril, and potassium chloride ordered, but the 9:00 AM MAR entries for that day were blank. Another resident with acute and chronic respiratory failure, COPD, heart failure, atrial fibrillation, and multiple cardiac and anticoagulant medications had orders for time-specific doses at 9:00 AM and 9:00 PM, including apixaban, hydralazine, sacubitril-valsartan, and isosorbide dinitrate, yet the 9:00 AM medications were not documented as given by 12:40 PM. A third resident with heart failure, COPD, diabetes, hepatitis C, and neuropathy had multiple scheduled medications and sliding scale insulin ordered before meals and at bedtime; documentation showed the last blood sugar check and insulin administration at 7:00 AM, with no documentation of a blood sugar check before the noon meal despite the resident already being in the dining room and a history of frequent sliding scale insulin coverage before meals. A fourth resident with dementia, hypertension, diabetes, hyperlipidemia, and anemia had several daily medications and nutritional supplements ordered at 9:00 AM and 5:00 PM, but the 9:00 AM medications were not documented as administered. When interviewed, the nurse assigned to the unit stated the morning medication pass was not completed due to a heavy med pass and acknowledged not notifying administration or the physician about the delays. The facility’s Medication Administration policy required medications to be given within 60 minutes of the scheduled time, but the policy did not address late or missed medications, and the DON could not explain the lack of documentation or notifications.

Surveyors also found failures in wound and dressing management for two residents. One resident with intact cognition and diagnoses including heart failure, peripheral vascular disease, and diabetes had a right knee abrasion care plan and a physician order to cleanse the abrasion and apply triple antibiotic ointment with a border gauze dressing on Monday, Wednesday, Friday, and as needed. On observation, the resident’s right leg dressing was visibly soiled, saturated, and dated 3/17, and the resident reported no one had offered to change it since that date. The Treatment Administration Record (TAR) showed the treatment documented as completed on 3/18 and 3/20 by the nurse manager, but the observed condition of the dressing and the resident’s report conflicted with that documentation. In another case, a cognitively intact resident admitted with pleural effusion, sepsis, and malnutrition was observed with an undated, worn bandage on the right hand that the resident stated had been applied at an outside appointment on 3/17/26 and had not been assessed or changed by facility staff. The same resident also had an undated foam border dressing on the left outer arm, which the resident reported had not been changed for a couple of days, despite a care plan requiring weekly head-to-toe skin assessments and a physician order for right arm abrasion care every Monday, Wednesday, Friday, and as needed. The TAR showed the right arm treatment marked as completed on 3/20 and left blank on 3/23, and a skin check dated 3/21 documented no skin issues. When the DON later removed the hand dressing, an old, soiled dressing was revealed over a scabbed area, and the DON confirmed that dressings should be dated and that nurses were expected to assess any dressing without an order and obtain appropriate treatment orders.

The facility’s Skin Management policy required licensed nurses to monitor, evaluate, and document changes in skin condition, including dressings and surrounding skin, and to notify the resident, responsible party, practitioner, DON/designee, and treatment team when a new area of skin impairment was identified. Despite these requirements, the observations and record reviews showed that dressings were left in place for extended periods without being changed, were not dated, and were not consistently assessed or documented. In addition, there were discrepancies between TAR documentation and the actual condition of residents’ dressings, with one nurse manager having documented treatments as completed on dates when the dressing remained unchanged and soiled. These actions and inactions led to deficiencies in ensuring medications and treatments were provided according to physician orders, resident needs, and facility policies.