Failure to Provide and Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that prescribed medications, including narcotic and IV antibiotics, were administered as ordered and were readily available for use for two residents. One resident with diagnoses including osteomyelitis, pressure ulcer, paraplegia, and muscle spasm did not receive multiple scheduled doses of IV ceftolozane-tazobactam due to the medication being unavailable or on hold, as documented in progress notes and the electronic medication administration record (EMAR). Additionally, this resident did not receive several scheduled doses of pregabalin for neuropathy pain because the medication was not available, with progress notes indicating repeated notifications to the pharmacy and delayed receipt of the medication. Another resident with multiple psychiatric diagnoses, including borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, experienced lapses in the administration of clonazepam, as evidenced by missing controlled drug record forms for several periods and instances where administration was not signed off. The facility's policy required contacting the pharmacy or supervisor if a medication was ordered but not present, but this was not consistently followed, resulting in missed doses for both residents.