Medication Unavailability Leads to Missed Doses
Penalty
Summary
The facility failed to ensure the availability of a physician-ordered medication for a resident, leading to a deficiency in pharmaceutical services. Resident 1, who had an open wound on the left lower leg and lymphedema, was alert, oriented, and able to communicate her needs. On December 12, 2024, a physician ordered Oxycontin to be administered every 12 hours for pain management. However, the medication administration record for December 2024 showed that the medication was not administered on December 14, 15, and 16, resulting in six missed doses. Nursing documentation indicated that the medication was unavailable from the pharmacy, leading to the failure in administering the prescribed medication.
Plan Of Correction
1. Resident 1 was assessed for pain and administered medication. 2. A facility wide audit was completed to determine if there were any other unavailable medications. 3. The Licensed Nurses were re-educated on providing medication from the ebox and notification of the DON if medications are not available. The DON will work directly with the pharmacy to ensure medication availability. 4. The DON or designee will conduct an audit of medication availability weekly x 4 weeks then monthly x 2 months to ensure ordered medications are available. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.