Failure to Timely Provide and Administer Cardiac Medications for New Admission
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of essential cardiac medications for a newly admitted resident diagnosed with acute congestive heart failure. Upon admission, the resident had physician orders for Carvedilol and Entresto to be administered starting the evening of admission, but these medications were not available and were not given as scheduled. The medication administration record showed that both medications were not administered at the prescribed times, and the first doses were delayed until the following evening. Additionally, Rivaroxaban and Spironolactone, which were part of the resident's hospital regimen and recommended for continued use, were not ordered until the day after admission, further delaying their administration. Interviews with the resident, the resident's wife, the DON, and the Administrator confirmed that the medications were not available on the day of admission and that the medication administration record was inaccurately coded as 'held' without physician parameters for holding the medications. The facility's policy required medications to be administered in a safe and timely manner as prescribed, but this was not followed, resulting in the resident not receiving critical heart medications as ordered.