F0658

E

Failure to Follow Physician Orders and Accurately Document Medications and Skin Assessments

Saint Louis, Missouri Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The facility failed to ensure physician orders were followed and that services met professional standards of quality, as evidenced by multiple documentation and administration errors for several residents. One cognitively intact resident with anxiety, depression, and bipolar disorder had an order for clonazepam 0.5 mg to be given every evening at 4:00 p.m. The March MAR showed clonazepam documented as administered on a specific date at 4:00 p.m., but the controlled drug administration record showed the last actual administration occurred the previous day and that 11 tablets remained. The resident reported not receiving the clonazepam dose on that date, stated they informed night shift staff, and was told the medication was documented as given. Observation of the narcotic box with an LPN confirmed 11 tablets remained, and the LPN stated they thought they had given the dose but must have signed it off in the electronic record without actually administering it.

Another resident with dementia, hypertension, hyperlipidemia, dysphagia, seizures, depression, hemiplegia, and major depressive disorder had multiple active orders, including scheduled lorazepam oral concentrate for anxiety every six hours, behavior and side-effect monitoring every shift, assistance with dressing and undressing every shift, weekly skin assessments, and topical anti-itch lotion and barrier cream. Review of the MAR and nurse’s administration record for February showed numerous blank entries where lorazepam doses, behavior observations, side-effect monitoring, and assistance with dressing were ordered but not documented, with missed documentation across dozens of opportunities. The treatment administration record for the same period also contained blank entries for weekly skin assessments and for the ordered topical anti-itch lotion and barrier cream, again with multiple missed documentation opportunities. Similar gaps continued into March, with additional blank entries for lorazepam administration, weekly skin assessments, and topical treatments.

Two additional residents with diagnoses including diabetes, hearing loss, schizophrenia, dementia, and bipolar disorder had physician orders for weekly skin assessments on specified shifts. For one cognitively intact resident, the March MAR showed weekly skin assessments ordered on Wednesday night shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab predated those dates. For another resident with moderately impaired cognition, the March MAR showed weekly skin assessments ordered on Monday evening shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab also predated those dates. In an interview, the Administrator and DON stated they expected weekly skin assessments to be completed and documented in both the assessment tab and MAR when ordered, and that medications should be administered per physician orders with documentation of reasons and physician notification when not administered.