Failure to Reconcile and Provide Medications as Ordered for New Admissions
Penalty
Summary
The facility failed to reconcile, obtain, and provide medications as ordered for two residents who were recently admitted or readmitted. For one resident with a history of seizures, brain neoplasm, myasthenia gravis, and chronic pain syndrome, multiple scheduled medications were not administered as ordered following admission. The resident's medication administration record (MAR) showed missed doses of several critical medications, including those for seizure control, pain management, and chronic conditions. The facility did not document physician notification or obtain orders to hold or adjust medications when they were unavailable, and some medications were not available in the facility's stock or electronic dispenser. For another resident with chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension, the MAR indicated that several prescribed medications were not administered after readmission. During medication administration, an LPN was observed unable to provide multiple ordered medications, including antibiotics, antihypertensives, and medications for heart failure and nausea. The staff member did not document that the pharmacy or physician was notified about the missing medications, despite facility policy requiring such notification when medications are unavailable or late. Facility policies reviewed indicated that medications should be administered as ordered and that the physician must be contacted if medications are unavailable or delayed. The policies also outlined procedures for medication reconciliation and ordering upon admission or readmission. However, in both cases, there was a lack of timely reconciliation, ordering, and administration of medications, as well as insufficient documentation of communication with physicians or the pharmacy regarding unavailable medications.