Failure to Ensure Availability of Ordered Medications
Penalty
Summary
The facility failed to ensure that ordered medications were available for administration to residents, as observed and documented in three separate cases. In one instance, an LPN was unable to administer Clopidogrel to a resident because the medication was not available at the time of the medication pass. Another resident, with multiple diagnoses including type two diabetes mellitus with a foot ulcer, COPD, and protein-calorie malnutrition, had several medications, including Losartan Potassium and Amlodipine, not administered due to waiting on pharmacy delivery, as noted in the electronic Medication Administration Record (MAR). Additionally, a resident with epilepsy did not receive Phenobarbital on multiple occasions because the medication was not available, with MAR notes indicating the physician was aware and the facility was awaiting pharmacy delivery. The Director of Nursing, who had only recently started at the facility, was unable to provide explanations for the unavailability of these medications but acknowledged being aware of ongoing pharmacy-related issues.