Failure to Administer Ordered Medications as Scheduled
Penalty
Summary
The deficiency involves a failure to ensure timely medication administration according to physician orders and the resident’s care plans. Facility policy dated January 4, 2026, required that all medications be administered safely and appropriately. Resident 2 had an MDS assessment indicating severe cognitive impairment, dependence on staff for daily care, need for two-person assistance with transfers, and wheelchair use. The resident had care plans for anemia, congestive heart failure requiring bumetanide, and behavior management requiring administration of medications as ordered. Physician orders directed that the resident receive 1 mg of bumetanide by mouth twice daily, 1 mg of risperidone (one-half tablet) by mouth once daily, and two 325 mg tablets of acetaminophen by mouth three times daily for pain. Review of the resident’s February 2026 medication administration record showed that on February 1, 2026, the scheduled 2:00 p.m. doses of bumetanide, risperidone, and acetaminophen were not administered. There was no documentation of adverse effects related to the missed doses. The physician was notified the following day, and no new orders were given. In an interview, the Nursing Home Administrator and Director of Nursing confirmed that the medications were not administered but should have been, establishing that the facility did not follow its own policy or the physician’s orders for medication administration for this resident.
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