Failure to Provide Ordered Respiratory Medications Due to Availability Issues
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered for two residents with chronic respiratory conditions. For one resident with chronic respiratory failure and hypoxia, there was an order for a Breztri inhaler to be given twice daily. Documentation showed that multiple doses were not administered because the medication was unavailable, with staff indicating that the pharmacy required management authorization due to the high cost. Despite pharmacy requests for authorization, the necessary approval was not completed, and the medication was not received or administered as ordered. Nursing staff documented the unavailability and contacted the pharmacy, but there was a lack of follow-up communication with management to resolve the issue, and the Director of Nursing was not aware that authorization was needed. Another resident with COPD and asthma had an order for an Advair inhaler to be administered twice daily. The medication administration records indicated several missed doses due to the inhaler being unavailable, with notes stating the pharmacy was contacted and the medication was on order. The resident reported not receiving the inhaler consistently during their stay. The pharmacy confirmed that the inhaler had been sent and should have been available for all scheduled doses, but documentation verified that not all doses were administered. The facility's policy required that if a regularly scheduled medication was not available, staff should document the reason, notify the physician if a certain number of doses were missed, and follow procedures for obtaining the medication. In both cases, there was a breakdown in communication and follow-through, resulting in residents not receiving their prescribed respiratory medications as ordered.