F0755

E

Failure to Follow Medication Orders and Timely Administration for a Resident

Lancaster, California Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and facility policy for one resident with multiple medical conditions, including diabetes mellitus, sequelae of intracerebral hemorrhage, and generalized weakness. The resident was admitted with PRN orders for bisacodyl suppositories every 12 hours as needed for constipation and milk of magnesia (MOM) if no bowel movement occurred in three days. Point of Care bowel movement records showed no bowel movements on several specific dates, yet the Medication Administration Record (MAR) indicated that bisacodyl and MOM were not administered on those days. During interview, an LVN confirmed that the resident had no bowel movements on those dates and that neither bisacodyl nor MOM was given as ordered, and the DON stated that the physician’s orders were not followed and that the medications should have been offered and administered or refusals documented.

The facility also failed to ensure accurate documentation and administration of bisacodyl on another date. A Change of Condition note documented that bisacodyl was administered to the resident’s frontal private area on a specific date, but the MAR did not show administration of bisacodyl on that date. The DON stated that an LVN administered the bisacodyl but did not document it on the MAR, and that the ADON later documented the administration because the LVN had not done so. Facility policy required that the person who prepares the dose must be the one who administers it and that the individual who administers the medication must record the administration on the MAR directly after giving the medication, including specific documentation requirements for PRN medications.

The facility further failed to follow physician orders for insulin glargine and to administer other scheduled medications within the facility’s required time frame. The resident had an order for daily insulin glargine to be held only if blood sugar was less than 100 mg/dl, but the MAR showed that insulin glargine was not administered on two dates when the resident’s blood sugar readings were above 100 mg/dl. An LVN and the DON both acknowledged that insulin glargine should have been administered on those dates and that it was not. Additionally, audit reports showed that enoxaparin, metformin, and metoprolol, all ordered on specific twice-daily schedules, were administered significantly later than the scheduled times on multiple days. The LVN and DON both stated that medications were supposed to be administered within one hour before or after the scheduled time, and that these medications were given outside that window, contrary to facility policy on timely medication administration.

Facility policies on administering medications, preparation and general guidelines, and insulin administration all required that medications be administered in accordance with written prescriber orders, that medications be given within 60 minutes of the scheduled time (except for meal-related orders), and that insulin type, dosage, and administration be verified against the physician’s order. The documented late administrations of enoxaparin, metformin, and metoprolol, the missed doses of insulin glargine when blood sugars were above the hold parameter, the failure to administer bisacodyl and MOM when bowel movement criteria were met, and the failure to document a given dose of bisacodyl on the MAR collectively demonstrate that the facility did not follow its own policies or the physician’s orders for this resident’s medications.