Failure to Administer Multiple Medications as Ordered for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for three residents. For one cognitively intact resident with hemiplegia, GERD, and chronic pain, multiple scheduled medications were not given on numerous documented dates in February. Missed medications included cyclobenzaprine, methocarbamol, and acetaminophen at 6:00 A.M. and 10:00 P.M., omeprazole at 5:00 A.M., and several 9:00 P.M. medications such as a Lidocaine patch, diclofenac gel, Senna S, atorvastatin, and melatonin. The Regional Clinical Director confirmed that these medications were not administered as ordered. A second cognitively intact resident with hypertensive heart disease with heart failure, intervertebral disc degeneration, and chronic pain syndrome also had multiple missed doses of ordered medications. Review of the MAR showed that several 9:00 P.M. medications, including atorvastatin, trazodone, tamsulosin, Advair Diskus, Biotene, Lyrica, Mucinex ER, naproxen, omeprazole, Senna S, sodium chloride, and valsartan, were not administered on multiple evenings in February. Additionally, buspirone and cyclobenzaprine were not administered at 6:00 A.M. and 10:00 P.M. on multiple dates, and levothyroxine at 6:00 A.M. and Pataday ophthalmic solution at 5:00 A.M. were also not given on several dates. The Regional Clinical Director verified these missed medications. A third resident with hemiplegia, epileptic seizures, and vascular dementia, who was assessed as severely cognitively impaired, had numerous missed doses of ordered medications as well. The February MAR showed that famotidine, melatonin, artificial tears, baclofen, Depakote sprinkles, and a house nutritional supplement were not administered at 9:00 P.M. on multiple dates. Levothyroxine at 6:00 A.M. and hydrocodone-acetaminophen at 6:00 A.M. and 10:00 P.M. were also not administered on several dates. The facility’s medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration, but the documented omissions show that medications were not given as ordered. The Regional Clinical Director confirmed the missed medications for this resident as well.
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.