F0760

D

Failure to Administer Ordered Medications and Prevent Significant Medication Errors

Maumee, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, as required by physician orders and facility policy. For one resident with hypertension, type 2 diabetes, osteoarthritis, heart failure, generalized anxiety disorder, and COPD, hospital discharge orders included multiple scheduled and PRN medications, with some medications specifically paused pending further physician instruction. On admission, the physician orders at the facility included furosemide, gabapentin, guaifenesin, lorazepam PRN, metformin, oxycodone PRN, tramadol PRN, and senna plus. The facility’s contingent medication supply included several of these medications. However, review of the MAR showed that no medications were administered on the admission date despite active physician orders and the availability of several ordered drugs in the contingent supply.

The resident later reported not receiving any evening medications on the admission date, including an anxiety medication that he stated he really needed. The Unit Manager LPN confirmed that the floor nurse was responsible for reviewing and entering medication orders for new admissions and that the nurse should have addressed medication orders first. The Unit Manager verified that the resident did not receive medications per physician orders on the admission date and acknowledged that the nurse should have pulled available medications from the contingent supply. She also stated that the resident could have received lorazepam for anxiety if the nurse had clarified the paused medication orders with the physician, and that the resident had voiced concerns about not receiving all medications.

For a second resident with schizoaffective disorder, dementia, chronic pain, anxiety, COPD, hypothyroidism, GERD, and epilepsy, physician orders included lacosamide, levothyroxine, pantoprazole, trazodone, lamotrigine (in combination to equal 125 mg twice daily), buspirone, acetaminophen, and rosuvastatin. Review of the MAR for the month showed multiple dates on which these medications were not administered as ordered, including missed doses of seizure medications, thyroid medication, GERD medication, cholesterol medication, pain medication, and psychotropic/anxiolytic medications. Nursing notes for the same period contained no documentation that the resident had refused any medications. The resident reported that nurses were not waking her up to give medications and that some nurses simply did not give her medications. The Regional Director of Clinical Services confirmed that the resident was not administered medications per physician orders and that there was no documentation of medication refusal. Facility policy stated that medications would be administered per physician orders, including any required time frame.