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Based on document review and interview, nursing services failed to document patient belongings upon admission and discharge in 6 of 10 (Patients 1, 2, 4, 5, 6, and 7) medical records reviewed; failed to notify the provider for medications not administered for 5 of 10 (Patient 1, 2, 5, 7, and 10) medical records reviewed ; and failed to accurately complete the daily fall risk assessment in 1 of 10 (Patient 6) medical records reviewed.

Findings include:

1. Facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, last approved 07/2023, indicated under Procedure: Admission, 4. Upon admission, staff will inventory all patient belongings, and sign the Personal Belongings Inventory Form. Patient will then sign the form.

2. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed.

3. Review of Patient 1's medical record indicated the following:
a. The patient was admitted on 03/21/2025.
b. On 03/13/2025, the MR indicated medication reconciliation was completed and the provider ordered for home medications to be continued which included the following medications: Toprol XI 100 mg (milligram) PO (by mouth) daily, Protonix 40 mg PO daily, Miralax 17 grams PO daily, Seroquel 50 mg PO BID (twice a day).
c. On 04/01/2025, the medication administration record (MAR) indicated the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO; the nursing note lacked documentation the provider was notified the above medications were not administered.
d. MR indicated the Patient Personal Effects Inventory form lacked documentation of the patient's or witness signature, date, and time upon admission and documentation indicating the patient received their personal belongings upon discharge.
e. The patient was discharged on 04/08/2025.

4. Review of Patient 2's medical record indicated the following:
a. The patient was admitted on 12/02/2024.
b. On 12/02/2024, the medical record indicated medication reconciliation was completed and the provider ordered for Vraylar 3 mg PO daily to be continued during patient's hospitalization.
c. The medication administration record indicated Vraylar 3 mg PO was not available on the following dates and were not administered to the patient: 12/18/2024 through 12/25/2024, 01/01/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/13/2025, 01/15/2025 through 01/25/2025, 01/27/2025, 01/28/2025, 02/03/2025, 02/05/2025, 02/11/2025, 02/19/2025, 02/24/2025, 02/26/2025 through 03/03/2025, and 03/05/2025 through 03/11/2025. The medication administration record lacked documentation of administration, refusal, or medication not available on the following dates: 01/29/2025 through 02/02/2025, 02/04/2025, and 03/12/2025. Medical record lacked documentation in the nursing notes of provider notifications that the medication was not available nor that the medication was not administered to the patient.
d. MR lacked documentation of the Patient Personal Effects Inventory form.
e. The patient was discharged on 03/13/2025.

5. Review of Patient 4's medical record indicated the following:
a. The patient was admitted on 02/25/2025.
b. MR lacked documentation of the Patient Personal Effects Inventory form.
c. The patient was discharged on 03/03/2025.

6. Review of Patient 5's medical record indicated the following:
a. The patient was admitted on 03/13/2025.
b. On 03/13/2025, the MR indicated medication reconciliation was completed and the provider ordered for home medications to be continued which included the following medications: Toprol XI 100 mg PO daily, Protonix 40 mg PO daily, Miralax 17 grams PO daily, Seroquel 50 mg PO BID.
c. On 03/24/2025, the medication administration record (MAR) indicated the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO; the nursing note lacked documentation the provider was notified the above medications were not administered.
d. MR lacked documentation of the Patient Personal Effects Inventory form.
e. The patient was discharged on 03/26/2025.

7. Review of Patient 6's medical record indicated the following:
a. Patient was admitted on 03/28/2024. The medical record indicated the patient's admission assessment fall risk assessment was marked low to moderate risk with a score of 75 using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk.
b. Medical record indicated the patient's day shift fall risk assessment was marked low to moderate risk on 03/18/2025, 03/22/2025, and 03/25/2025 with a score of 90 for all dates using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk.
c. Medical record indicated the patient's day shift fall assessment was marked no risk on 03/28/2025 with a score of 65 using the Morse Fall Scale. The Morse Fall Scale indicates a score greater than 45 is high risk.
d. Medical record indicated the Patient Personal Effects Inventory form lacked documentation of the patient's or witness signature, date, and time upon admission and documentation indicating the patient received their personal belongings upon discharge.
e. Patient was discharged against medical advice (AMA) on 03/28/2025.

8. Review of Patient 7's medical record indicated the following:
a. Patient was admitted on 03/30/2025.
b. On 03/30/2025, the medical record indicated medication reconciliation was completed and the provider ordered Pimavanserin Tartrate (Nuplazid) 25 mg PO daily to be continued during patient's hospitalization.
c. On 03/31/2025 through 04/10/2025, the medication administration record indicated Pimavanserin Tartrate (Nuplazid) 25 mg PO was not available and was not administered to the patient. The medical record lacked documentation of provider notification the medication was not administered and not available.
d. MR indicated the Patient Personal Effects Inventory form lacked documentation of the patient's or witness signature, date, and time upon admission and documentation indicating the patient received their personal belongings upon discharge.
e. The patient was discharged on 04/10/2025.

9. Review of Patient 10's medical record indicated the following:
a. Patient was admitted on 04/08/2025.
b. On 04/09/2025, the medical record indicated the ordered Zinc Gluconate 25 mg, 1 tablet, PO daily was to be substituted to Zinc Sulfate 220 mg PO daily.
c. On 04/10/2025 through 04/15/2025, the medication administration record indicated that Zinc Sulfate 220 mg PO was not available. The medical record lacked documentation of provider notification that the medication was not administered and not available.
e. Patient was a current inpatient.

10. Interview with A1 (Director of Quality and Risk) on 04/17/2025 at approximately 5:30 p.m. confirmed the above findings.

Based on document review and interview, nursing services failed to administer ordered and scheduled medications for 5 of 10 patient (Patient 1, 2, 5, 7, and 10) medical records reviewed.

Findings include:

1. Facility policy titled, Standardized Medication Administration, PolicyStat ID 12197198, last approved 08/2022, indicated under General Knowledge, E. All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed.

2. Facility policy titled, Generic Substitution, Policy Number - PHR-106, Origination Date: 03/2024, indicated under 4.0 Procedure: 4.2 The Pharmacy Department will attempt to locate the drug from a local Pharmacy or hospital if the medication is not stocked at the facility.

3. Review of Patient 1's medical record indicated the following:
a. The patient was admitted on 03/21/2025.
a. On 03/21/2025, provider orders indicated Aricept 5 milligrams (mg) by mouth (PO) daily, Namenda 5 mg PO twice a day (BID) and Tagamet 400 mg BID were ordered and Norvasc 5 mg daily and Protonix 40 mg PO daily were to be continued from patient's home medication list.
c. On 04/01/2025, the medication administration record (MAR) indicated the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO.

4. Review of Patient 2's medical record indicated the following:
a. The patient was admitted on 12/02/2024.
b. On 12/02/2024, the medical record indicated medication reconciliation was completed and the provider ordered for Vraylar 3 mg PO daily to be continued during patient's hospitalization.
c. The medication administration record indicated Vraylar 3 mg PO was not available, was not administered, or lacked documentation on the following dates: 12/18/2024 through 12/25/2024, 01/01/2025, 01/06/2025, 01/08/2025, 01/10/2025, 01/13/2025, 01/15/2025 through 01/25/2025, 01/27/2025 through 02/05/2025, 02/11/2025, 02/19/2025, 02/24/2025, 02/26/2025 through 03/03/2025, and 03/05/2025 through 03/12/2025.

5. Review of Patient 5's medical record indicated the following:
a. The patient was admitted on 03/13/2025.
b. On 03/13/2025, the MR indicated medication reconciliation was completed and the provider ordered for home medications to be continued which included the following medications: Toprol XI 100 mg PO daily, Protonix 40 mg PO daily, Miralax 17 grams PO daily, Seroquel 50 mg PO BID.
c. On 03/24/2025, the medication administration record (MAR) indicated on 04/01/2025, the patient was not administered their 9:00 a.m. scheduled medications which included the following: Toprol XI 100 mg PO, Protonix 40 mg PO, Miralax 17 grams PO, and Seroquel 50 mg PO.

6. Review of Patient 7's medical record indicated the following:
a. Patient was admitted on 03/30/2024.
b. On 03/30/2025, the medical record indicated medication reconciliation was completed and the provider ordered Pimavanserin Tartrate (Nuplazid) 25 mg PO daily to be continued during patient's hospitalization.
c. On 03/31/2025 through 04/10/2025, the medication administration record indicated Pimavanserin Tartrate (Nuplazid) 25 mg PO was not available and was not administered to the patient.

7. Review of Patient 10's medical record indicated the following:
a. Patient was admitted on 04/08/2025.
b. On 04/09/2025, the medical record indicated the ordered Zinc Gluconate 25 mg, 1 tablet, PO daily was to be substituted to Zinc Sulfate 220 mg PO daily.
c. On 04/10/2025 through 04/15/2025, the medication administration record indicated Zinc Sulfate 220 mg PO was not available and was not administered to the patient.

8. Interview with A1 (Director of Quality and Risk) on 04/17/2025 at approximately 3:05 p.m. confirmed that patients 1, 2, 5, 7 and 10's MR lacked documentation of ordered medication administration as indicated above.