F0755

E

Widespread Failures in Timely and Accurate Medication Administration and Documentation

Watertown, Wisconsin Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate and timely medication administration in accordance with physician orders and facility policy for multiple residents. The facility’s Medication Administration policy required medications to be administered as prescribed, within 60 minutes of scheduled times, with clear documentation and clarification of unclear orders. For one resident with multiple severe pressure ulcers and osteomyelitis, an order for 5% acetic acid stated only to apply externally every day and evening shift, without specifying the location, method of application, or treatment parameters. Review of the MAR showed that 11 of 44 scheduled doses were not documented as administered, with 10 doses coded as “other” and one as “refused,” and no corresponding progress notes explaining the “other” codes. Nursing staff, including an LPN and the DON, stated they did not know where the acetic acid should be applied or the indication for its use and acknowledged the order was unclear and should have been clarified. Another staff member reported never applying the acetic acid despite documenting it as given and stated they had been pressured by the wound nurse to sign out medications and treatments they did not administer.

A second resident with paraplegia, sepsis, anxiety, and depression had been on methenamine hippurate twice daily for frequent UTIs. After a hospitalization for sepsis with possible UTI, the hospital discharge summary instructed that methenamine be held during a 7‑day course of Bactrim and then resumed three days after completion, specifying a resume date. The facility did not restart methenamine hippurate until 11 days after the date indicated in the discharge instructions. The ADON, who also served as Infection Preventionist, confirmed that the methenamine should have been resumed per the hospital instructions and stated the order had been missed.

Additional residents experienced late or unavailable medications and administration not in accordance with orders. One cognitively intact resident reported that morning medications, including olanzapine, glipizide ER, and fluoxetine, were sometimes late; an audit showed these 8:00 AM medications were administered around midday. Another resident admitted with atrial fibrillation, hypertension, and rheumatoid arthritis had multiple essential medications, including amiodarone, hydroxychloroquine, metoprolol, and sulfasalazine, not administered on several days because they were unavailable, as documented on the MAR. Several other residents had scheduled morning medications (including metformin, methenamine, acetaminophen, antihypertensives, anticoagulants, psychotropics, and other chronic medications) ordered for 7:00 or 8:00 AM but observed being administered after 9:00 AM; the RN administering these medications acknowledged they were late and stated that morning medications were given between 7:00 and 11:00 AM. The DON stated medications should be administered within one hour before or after the prescribed time.

Another cognitively intact resident with epilepsy, diabetes, asthma, and anxiety reported needing seizure medications on time and stated that seizure medications were given two hours late, leading to small seizures, which the resident described to nursing staff and the DON. The MAR showed multiple doses of lacosamide and levetiracetam scheduled for 8:00 AM and 4:00 PM were administered late, coded as “other,” or documented as given significantly outside the scheduled times, with some doses of levetiracetam administered several hours after the scheduled time. Nurses’ notes for the dates with “other” codes were not available for review, and there were no progress notes documenting seizure activity. A pharmacist later explained that twice‑daily medications are recommended to be given at least eight hours apart and preferably closer to 12 hours, and confirmed that certain doses of levetiracetam were supplied in limited quantities due to insurance refill timing, with the possibility that the resident had home supply, but the MAR still reflected late administrations and code entries.