F0684

E

Missed Evening Medication Administration on Two Units Due to Key and Staffing Issues

Kent, Ohio Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer ordered evening medications to multiple residents on specific units on 02/21/26. On that evening, residents with various diagnoses, including cellulitis, hypothyroidism, obesity, diabetes mellitus, congestive heart failure, lymphedema, COPD, emphysema, atrial fibrillation, necrotizing fasciitis, acute respiratory failure, dementia, schizophrenia, Alzheimer’s disease, seizure disorders, and insomnia, did not receive their prescribed nighttime medications. Medication Administration Record (MAR) reviews for 16 residents showed that a wide range of medications were not given, including antidiabetic agents, anticoagulants, antipsychotics, antidepressants, antiepileptics, antihypertensives, cholesterol-lowering agents, sleep aids, inhalers, supplements, nutritional products, and other routine medications.

For example, one resident with cellulitis, hypothyroidism, and obesity did not receive a probiotic, desmopressin, levothyroxine, collagen supplement, protein supplement, and an antihistamine. Another resident with type 2 diabetes mellitus, morbid obesity, and depression did not receive colchicine. A resident with congestive heart failure, lymphedema, and diabetes insipidus missed doses of ezetimibe, metformin, collagen supplement, acetaminophen, gabapentin, and a protein supplement. Residents with COPD, emphysema, and atrial fibrillation did not receive multiple medications including melatonin, montelukast, Protonix, trazodone, apixaban, metoprolol, omega-3, Pulmicort, senna, Combivent, Haldol, and Tylenol. Additional residents with recent admissions and serious conditions such as necrotizing fasciitis and acute respiratory failure missed evening doses of atorvastatin.

Other residents with dementia, Alzheimer’s disease, schizophrenia, vascular dementia, atrial fibrillation, senile brain degeneration, catatonic schizophrenia, intermittent explosive disorder, seizures, visual hallucinations, and overactive bladder also did not receive their ordered evening medications. These included donepezil, divalproex, melatonin, trazodone, Zyprexa, Seroquel, Ativan, Flomax, gabapentin, Keppra, magnesium oxide, memantine, metformin, Prilosec, Remeron, rivaroxaban, hydroxyzine, Symbicort, fluphenazine decanoate, aspirin, risperidone, benztropine, clonazepam, thiamine, Lantus, Eliquis, Humalog, and various nutritional supplements such as Ensure Plus, Magic Cup, Glucerna, and ProStat. The inaction that led to this deficiency was that no nighttime medications were administered to residents on the 300 and 400 halls during that shift, despite the presence of a nurse in the facility.

Interviews with the Administrator and DON clarified the sequence of events leading to the missed medication administration. The Assistant Director of Nursing (ADON) had been called in to work the day shift and, when her shift ended at 7:00 P.M., her replacement did not arrive. The ADON then left the facility, quit her job, and dropped the medication cart keys at the Administrator’s home. Although there was still a nurse in the facility and extra medication cart keys were available in the Administrator’s office, the nurse on duty refused to take the keys because they had not been formally signed out to her. As a result, no residents on the 300 and 400 halls received their prescribed nighttime medications on that date. The facility’s self-reported investigation confirmed that the nurse left around 7:30 P.M. with the medication cart keys and that no nighttime medications were administered on those halls during that shift.