F0760

D

Repeated Medication Omissions and Inconsistent Administration

Olympia, Washington Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure medications were administered as ordered, resulting in repeated omissions of multiple prescribed drugs for one resident. The resident had diagnoses including alcoholic cirrhosis, esophageal varices, and ADHD, and was assessed as having no cognitive impairment with partial to moderate dependence for activities of daily living. The resident reported that staff did not pass all daily medications, including liver-related supplements, and that Adderall was not administered consistently, which the resident stated affected decision-making and increased stress. A January Medication Review Report listed folic acid, Sarna eczema relief lotion, Adderall, and carvedilol among the resident’s prescribed medications.

The January MAR documented numerous missed doses: folic acid was missed 15 of 21 times, the eczema relief lotion 9 of 41 times, Adderall 8 of 21 times, and carvedilol 11 of 41 times. During an observed medication pass, an LPN did not administer folic acid, thiamine, or the eczema relief lotion to the resident. The LPN later stated he could not find the folic acid and did not retrieve more, acknowledged that thiamine was given but not at the scheduled time, and confirmed the lotion was not given. He also stated the resident had 16 tablets of Adderall available and verified that Adderall had not been administered the previous day or on many prior days, without being able to explain why it was not given. These observations and record reviews showed that ordered medications were not consistently administered as prescribed.