Deficiency #1
Rule/Regulation Violated:
R9-10-817.B.3.a-c. Medication Services<br> B. If an assisted living facility provides medication administration, a manager shall ensure that: <br>3. A medication administered to a resident: <br>a. Is administered by an individual under the direction of a medical practitioner, <br>b. Is administered in compliance with a medication order, and <br>c. Is documented in the resident’s medical record.
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order and documented in the medical record. </p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">Findings include:</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;"> </span></p><p>1. A review of R6’s medical record revealed an order for “Glucerna Oral Liquid, Give 237 ml by mouth one time a day.” In addition, the record contained an order for “SITagliptin Oral Tablet 100 MG, Give 1 tablet by mouth one time a day for diabetes.” Further review revealed a medication administration record (MAR) for documenting the administration of medications during June 2025. The record included sections for documenting the administration of “Glucerna Oral Liquid, 237 ml, by mouth daily,” and “SITagliptin 100 MG, 1 tablet by mouth daily.” The record reflected documentation indicating R6 refused to take Glucerna every day in June, and SITagliptin from June 1 through June 24, 2025. </p><p> </p><p> </p><p> </p><p>2. A review of R6’s medical record revealed a document titled “Physician Communication Form,” dated June 30, 2025. Documentation of any attempt to contact R6's physician regarding R6's refusal to take ordered medication before June 30, 2025, was unavailable for review. The Physician Communication Form included a section titled “Message,” which read “[R6] refusing to take med. Please advise.” The form also included a section titled “Physician Orders/Response:” which read “Okay to D/C 1-Sitagliptin 100mg, 2-Glucerna oral Liquid,” and was signed by R6’s primary care provider on July 1, 2025. </p><p> </p><p> </p><p> </p><p>3. In an interview, E1 advised R6 had been refusing to take Glucerna and Sitagliptin as ordered. E1 said they were not aware of any efforts to contact R6’s medical provider prior to June 30, 2025. E1 agreed R6 had not received medication as ordered.</p>
Temporary Solution:
Medication refusal policy has been updated as of 10/31/2025 -
6. REFUSAL- If a regularly scheduled medication is refused by the resident, circle the time in the correct space on the MAR, write on back of form why the medication was not administered to the resident. IF A RESIDENT IS REFUSING A PERSCRIBED MEDICATION THAT IS DETRIMENTAL TO HEALTH LESS THAN 3X IN A ROW BUT ON A REGULAR BASIS A MEDICATION REFUSAL FORM WILL BE FAXED TO THE PCP WITHIN 24 HOURS, THE FAMILY NOTIFIED WITHIN 24 HOURS, AND AN INCIDENT REPORT WILL BE SUBMITTED WITHIN 24 HOURS FOR REVIEW BY THE COMMUNITY LPN,AS WELL AS ADMINISTRATION. If any other medications more than 3 days in a row are refused, complete a Medication Refusal fax form, fax to physician immediately and enter an incident report. All medication refusals that are 3 days or more will be followed up by the community nurse with the resident’s physician for a plan of action. Any reported refusals and action plans will also be discussed at weekly administration meeting as well as monthly QM meeting.
Permanent Solution:
6. REFUSAL- If a regularly scheduled medication is refused by the resident, circle the time in the correct space on the MAR, write on back of form why the medication was not administered to the resident. administered to the resident. IF A RESIDENT IS REFUSING A PERSCRIBED MEDICATION THAT IS DETRIMENTAL TO HEALTH LESS THAN 3X IN A ROW BUT ON A REGULAR BASIS A MEDICATION REFUSAL FORM WILL BE FAXED TO THE PCP WITHIN 24 HOURS, THE FAMILY NOTIFIED WITHIN 24 HOURS, AND AN INCIDENT REPORT WILL BE SUBMITTED WITHIN 24 HOURS FOR REVIEW BY THE COMMUNITY LPN,AS WELL AS ADMINISTRATION. If any other medications more than 3 days in a row are refused, complete a Medication Refusal fax form, fax to physician immediately and enter an incident report. All medication refusals that are 3 days or more will be followed up by the community nurse with the resident’s physician for a plan of action. Any reported refusals and action plans will also be discussed at monthly QM meeting.
Care staff/med techs are currently all being in serviced on the new policy, including the refusal fax form, and notification requirements in the policy up date stated above.
Person Responsible:
Deborah Hall Executive Director
Summary:
The following deficiencies were found during the on-site investigation of complaints 00137554 and 00142024, conducted on August 26, 2025: