Failure to Ensure Timely Availability of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were available for administration to residents, resulting in two residents not receiving their prescribed medications as ordered. One resident, who had a history of chronic pain and migraines, reported running out of Tramadol, a pain medication she routinely took twice daily. She stated that it sometimes took days for the facility to obtain her medication and that she was informed the previous night that she was on her last pill. The medication was not available during the morning medication pass, and the nurse confirmed it had last been administered the previous evening. The nurse also indicated that medications should be reordered when there are eight pills remaining, but this was not done in time for this resident. Another resident, with diagnoses including schizophrenia, anxiety disorder, and psychosis, did not receive her scheduled dose of Aripiprazole because the medication was not available during the morning medication pass. The LPN responsible for her care stated she was not notified by the night shift that the medication had run out and only reordered it that morning. The facility's policy requires medications to be reordered according to the pharmacy provider's schedule, but this was not followed, resulting in missed doses for both residents.