Failure to Provide Timely Medication Due to Unavailability and Prescription Issues
Penalty
Summary
The facility failed to ensure that medications were available for a resident who was severely cognitively impaired and had multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. The resident had a physician's order for tramadol 50 mg twice daily, but the medication was not administered on several occasions due to it being unavailable. Documentation showed missed doses on multiple dates, with reasons including the medication being out of stock and the need for a new prescription. Progress notes indicated that staff recognized the need for a new prescription and attempted to communicate this to the provider, but there was no evidence in the physician progress notes that a new prescription was requested or provided in a timely manner. Facility policy required reordering medications several days in advance and obtaining new prescriptions as needed, but these procedures were not followed, resulting in the resident missing multiple doses of prescribed pain medication.