Failure to Administer Ordered Antipsychotic Medication Due to Unavailability
Penalty
Summary
The facility failed to administer an antipsychotic medication, Seroquel XR, as ordered by the physician for one resident. According to the Medication Administration Record (MAR) and physician's order, the resident was to receive 1.5 tablets of Seroquel XR 50 mg by mouth at bedtime. However, on multiple dates, the medication was not administered because it was not available, as documented in the progress notes. The MAR indicated missed doses on six separate days, with corresponding notes stating the medication was pending delivery and not available for administration. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the resident did not receive the ordered medication on the specified dates. The LVN acknowledged not administering the medication due to its absence in the medication cart and admitted to not notifying the pharmacy or the physician about the unavailability. The facility's policy required nursing staff to contact the prescriber if medication delivery was delayed or unavailable, but this procedure was not followed in this instance.