F0755

E

Failure to Administer Multiple Physician-Ordered Medications

Toledo, Ohio Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide routine medications and biologicals as ordered by physicians for multiple residents, resulting in missed doses documented on the Medication Administration Records (MARs) and confirmed by the Director of Nursing (DON). For one resident with alcohol abuse, depression, anxiety, HTN, insomnia, and vitamin deficiencies, physician orders for daily cholecalciferol and cyanocobalamin were in place, but the resident did not receive these medications on a specified date. Another resident with extensive cardiac, respiratory, renal, and neurologic conditions, including anoxic brain damage, NSTEMI, heart failure, CKD3B, seizures, and depression, had orders for daily aspirin for antiplatelet therapy and a lidocaine patch for pain; these medications were also not administered on the same date.

Additional residents with complex medical histories similarly did not receive ordered medications. One resident with anoxic brain damage, acute respiratory failure, intracerebral hemorrhage, seizures, dysphagia, CHF, and other conditions had physician orders for daily aspirin, MiraLAX, and chlorhexidine gluconate mouth/throat solution; none of these were given on the identified date. Another resident with malignant neoplasm of the prostate, severe protein-calorie malnutrition, hepatitis C, SVT, HTN, chronic pain, and other diagnoses had multiple daily medications ordered, including cetirizine, magnesium, a multivitamin, pantoprazole, potassium chloride, and vitamin D3, all of which were not administered on that date. A resident with central cord syndrome, severe malnutrition, TIA, COPD, epilepsy, quadriplegia, and other comorbidities had orders for aspirin, a lidocaine patch, and scheduled acetaminophen; the aspirin, lidocaine patch, and two scheduled doses of acetaminophen were not given on the same date.

Further review showed that other residents also did not receive ordered medications. One resident with COPD, DM2, functional quadriplegia, dementia, and malnutrition had orders for aspirin, ergocalciferol, vitamin B12, and magnesium, which were not administered on the specified date. Another resident with COPD, DM2, malnutrition, OSA, ARF, heart disease, HTN, hypothyroidism, TIA, neurocognitive disorder, schizoaffective disorder, and convulsions had multiple ordered medications, including aspirin, potassium chloride, ProStat, vitamin C, cyclosporine ophthalmic drops, and famotidine; the morning doses of these medications were not given. A resident with monoplegia following cerebral infarction, HTN, depression, GERD, hyperlipidemia, atherosclerotic heart disease, DM2, and other neurologic conditions had an order for daily aspirin for DVT prevention that was not administered. Another resident with chronic respiratory failure, major depressive disorder, BPH, atrial fibrillation, HTN, OSA, COPD, neuropathy, and other conditions had multiple orders, including a multivitamin, polyethylene glycol, vitamin D, azelaic acid gel, potassium chloride, sennosides-docusate, and Ensure; the MAR showed that the resident did not receive these medications and supplements as ordered on the identified date. The DON confirmed in each case that the ordered medications were not administered. The facility’s own resident agreement and medication administration policy require adequate and appropriate medical treatment and that medications be administered in accordance with professional standards of practice, but these requirements were not met in the instances cited.