Failure to Administer Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by physicians for two of four residents reviewed for pharmacy services. One resident, who had multiple diagnoses including a three-part fracture of the left humerus, COPD, neuropathy, major depressive disorder, CHF, cardiac pacemaker and defibrillator, history of falling, arthropathy, gout, hypertension, low back pain, and chronic atrial fibrillation, did not receive several prescribed medications on two consecutive days. Documentation in the Medication Administration Record (MAR) and progress notes indicated that these medications were not administered because they were not available on hand. Another resident, diagnosed with GERD, reported not receiving her prescribed calcium carbonate tablets after meals for several days, resulting in a total of eight missed doses. The MAR confirmed these omissions, and the resident's care plan specifically included the intervention to administer medications as ordered. The facility's policy requires all medications to be administered safely and appropriately, and the Director of Nurses confirmed that medications are to be given as ordered by the physician.