Failure to Reorder and Provide Prescribed Medications
Penalty
Summary
The facility failed to ensure the timely reordering and availability of prescribed medications for multiple residents. During observations and record reviews, it was found that one resident did not have access to their ordered DuoNeb and Hydrocodone-Acetaminophen, as confirmed by a registered nurse who reconciled the resident's medication orders with the medications on hand. Another resident missed a scheduled dose of Flonase nasal spray, and upon further review, it was determined that Flonase, Midodrine, Nystatin, and Triamcinolone Acetonide were not available for administration as prescribed. A third resident was also found to be without several ordered medications, including Diclofenac, DuoNeb, Guaifenesin-Codeine, and Insulin Aspart, as verified by a registered nurse through reconciliation of the order summary and available medications. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for nurses to reorder medications before supplies were depleted to ensure continuous availability for administration. The facility's policy on medication availability requires staff to inform the pharmacy of shortages or limited supplies. Despite these policies, the prescribed medications for the affected residents were not reordered in a timely manner, resulting in their unavailability at the time of administration.