Failure to Obtain and Administer Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician-ordered medications were obtained from the pharmacy and administered at the designated times for three residents. For one resident with diagnoses including hypertension and hyperlipidemia, there were multiple documented instances where prescribed medications such as amlodipine besylate and atorvastatin calcium were not administered as ordered. The medication administration record (MAR) indicated missed doses, with pharmacy alerts showing that orders would not be filled due to rejection, requiring resubmission at a later date. Staff interviews confirmed that the medications were not available and that communication regarding missing medications was relayed to nursing staff. Another resident with chronic diastolic heart failure, Parkinsonism, and other conditions did not receive several doses of critical medications, including Sinemet, amiodarone hydrochloride, and apixaban, as ordered by the physician. The MAR showed missed doses without documented reasons or with codes indicating the need to see nurse notes. Pharmacy alerts indicated that some medication orders were rejected and not filled. Interviews with the DON and Corporate Nurse Consultant revealed that the process for reordering medications involved using the MAR, and if medications were unavailable, staff were expected to use emergency supplies or contact the pharmacy. A third resident with hypertension did not receive several doses of Tiadylt ER as ordered. The MAR reflected missed doses, some without documentation and others marked with a code for further explanation. Pharmacy staff indicated that a new order was required and that a billing issue delayed delivery. Additional interviews with facility staff and pharmacy personnel highlighted ongoing problems with the pharmacy reordering process and communication issues, resulting in delays in medication delivery and administration.