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Based on interview and record review, the facility failed to ensure one (Patient #1) of ten patients received medications as ordered. The census was 569 patients.

Findings include:

A review of Patient #1's clinical record revealed the patient was admitted to the facility on 07/05/18 with a diagnosis of right lower leg cellulitis and a past medical history significant for recent hospitalization for septic cholecystitis followed by acute hypoxic respiratory failure.

The medical record review revealed a physician's order dated 07/19/18 at 10:29 PM to give vasopressin intravenously at a rate of 0.04 units per minute. Nursing notes dated 07/19/18 at 11:35 P.M. documented the medication was not given and "doesn't meet clinical criteria." The physician order was discontinued on 07/24/18 at 1:48 P.M.. The medical record review did not reveal where the medication was ever given. The medical record review did not reveal any discussion between nursing and medicine as to why the order stayed on the books for six days, but not given.

On 08/21/18 at 5:05 P.M. during interview, Staff M confirmed the finding and explained if there isn't any documentation on why a scheduled medication is not given, the computer will generate a overdue report for the day. She said if there is no documentation for a day for a medication given continuously, like intravenous medications, no such overdue report is generated.

This deficiency substantiates Substantial Allegation OH00099602 and OH00099645.