Rule/Regulation Violated:
B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
b. Is administered in compliance with a medication order, and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of three residents sampled. The deficient practice posed a risk to the health and safety of residents as medications were not administered as ordered.
1. A review of R1's medical record revealed R1 received medication administration.
2. A review of R1's medical record revealed signed medication orders for the following medications:
-Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate), 3 ml three times a day;
-Fluticasone Proprionate Nasal Suspension 50MCG/ACT, 1 spray into each nostril two times a day; and
-Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone Salmeterol), 1 puff every 12 hours.
3. A review of R1's medication administration record (MAR) revealed all of the aformentioned medications were documented on the MAR to be administered as needed (not scheduled).
4. A review of R1's MAR revealed R1 had not received medication administration of any of the aforementioned medications in July 2023 or August 2023.
5. In an interview, E1 acknowledged the aformentioned medications were not being administered in compliance with a medication order. E1 reported E1 thought the aforementioned medications were on the MAR as routine medications. E1 reported R1 "sometimes" refused the medications, but the refusal was not documented.
6. A review of R2's medical record revealed R2 received medication administration.
7. A review of R2's medical record revealed a signed medication order for Temazapam 15 milligrams (mg), one capsule at bedtime.
8. A review of R2's medication administration record (MAR) revealed R2 received Temazapam 15 mg from August 1, 2023-August 17, 2023.
9. A review of R2's medications revealed no Temazapam available for use.
10. In an interview, E1 reported R2 had been out of Temazapam since August 13, 2023. However, a documentation error indicated R2 received the medication August 14, 2023-August 17, 2023.
11. A review of R2's medication administration record (MAR) revealed R2 was administered the following scheduled medications:
-Trazodone 150 milligrams (mg), one tablet at bedtime;
-Pantoprazole 40 mg every day, one tablet every day;
-Docusate 100 mg, two capsules every day;
-Bethanechol 25 mg, 1/2 tablet twice a day; and
-Tamsulosin 0.4 mg, one tablet at bedtime.
12. A review of R2's medical record revealed no signed medication orders for the aforementioned medications.
13. In an interview, E1 acknowledged R2's medications were not administered in compliance with a medication order, as there were no medication orders for review. E1 reported in the future, E1 would "call each month and get an updated medlist."
14. In an interview, E1 reported R3 received medication administration.
15. A review of R3's medical record revealed a signed medication list dated July 28, 2023. The medication list included the following medications:
-Bupropion ER (XL) Tab ER 24 hr 300 milligrams (mg), 1 tablet daily;
-Calcitriol Cap 0.25 mcg, 1 capsule daily;
-Cholestyramine Powder, 1/2 scoop daily in water;
-Depakote Sprinkles capsule delayed release 125 mg, 1 capsule 2 times daily;
-Donepezil Tab 10 mg, 1 tablet at bedtime;
-Duloxetine cap delayed release 60 mg, 1 capsule daily;
-Keppra Tab 1000 mg, 1 tablet every 12 hours;
-Losartan Potassium Tab 50 mg, 1 tablet daily;
-Pepcid Tab 20 mg, 1 tablet daily; and
-Quetiapine Fumarate Tab 50 mg, one tablet twice daily.
16. A review of R3's medical record revealed a medication administration record (MAR) for July 2023. The MAR indicated R3 received the following medications on July 30, 2023 and July 31, 2023:
-Keppra Tab 1000 mg;
-Duloxetine cap delayed release 60 mg;
-Losartan Potassium Tab 50 mg; and
-Bupropion ER (XL) Tab ER 24 hr 300 mg.
There was no additional documentation that indicated R3 received any other medications in July 2023 or August 2023.
17. In an interview, E1 reported O1 was given (or took) a lot of original documentation when R3 was taken to the hospital. E1 acknowledged there was no way to determine if R3 received the correct medications in compliance with a medication order.
This is a repeat deficiency from the on-site inspection completed May 11, 2022.
Summary:
The following deficiencies were found during the on-site compliance inspection conducted on April 2, 2025: