Failure to Administer and Document Medications Timely and as Ordered
Penalty
Summary
The facility failed to ensure medications were administered timely and in accordance with professional standards for two cognitively intact residents. One resident, with a Brief Interview for Mental Status (BIMS) score of 15 and chronic pain in the arm and leg, reported that medications were sometimes given on time and sometimes not, and that waiting for medications worsened the pain. Review of this resident’s physician orders dated 7/5/24 showed an order for Diclofenac Sodium 1% topical gel to be applied to the shoulders twice daily for chronic pain. Review of the Medication Administration Record (MAR) for February 2026, confirmed by the Director of Nursing (DON), showed that on 2/11/26 the 5 p.m. dose of Diclofenac gel was documented as administered at 8:17 p.m., which was 3 hours and 17 minutes after the scheduled administration time, outside the facility’s policy requirement that medications be administered within one hour of the prescribed time. A second resident, also with a BIMS score of 15, reported using the call light to request breathing treatments and having to wait 20–30 minutes before going to the nurse’s station. This resident further stated that a stomach medication was not received about a week prior, despite informing the nurse. Review of this resident’s MAR for February 2026 with the DON showed an order for Ipratropium/Albuterol 3 ml via nebulizer four times daily for shortness of breath or wheezing, with a start date of 7/26/25, and an order for Pantoprazole 40 mg delayed-release tablet by mouth once daily at 6 a.m. for esophagitis, with a start date of 1/24/26. On 2/18/26 at the 6 a.m. administration time, both the Ipratropium/Albuterol and Pantoprazole doses were left blank on the MAR, indicating they were not documented as administered, contrary to the facility’s medication administration policy requiring safe, timely administration as prescribed and documentation of the date and time medications are given.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.