Failure to Provide Ordered Medication Due to Pharmacy Out-of-Stock
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate provision of medications for one resident. According to the facility's policy, pharmacy services are to be provided routinely and in a timely manner. However, a review of the clinical record for a resident admitted with diagnoses including anemia, kidney stones, and Alzheimer's Disease revealed that a physician's order for TheraLith XR, to be administered twice daily, was not followed. The resident did not receive nine doses of the medication between 4/24/25 and 4/28/25, as documented in the Medication Administration Record. Progress notes and staff interviews confirmed that the medication was unavailable from the pharmacy during this period. On 4/29/25, during a medication pass, the medication was still not in stock, and both a registered nurse and the Director of Nursing verified that the pharmacy was out of TheraLith, resulting in the resident not receiving the medication as ordered. The Nursing Home Administrator also confirmed the failure to implement pharmaceutical services to ensure accurate medication provision for the resident.