Failure to Timely Order and Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring timely ordering and administration of a prescribed medication. A female resident with a history of stroke, hemiparesis, contractures, hypertension, anxiety disorder, and pain was prescribed methocarbamol (Robaxin) 750 mg twice daily for muscle spasms. On the morning of 5/13/25, the resident did not receive her scheduled dose because the medication was not available, as indicated in the Medication Administration Record and confirmed by staff interviews. The resident reported that she had been informed the previous evening that her Robaxin supply was running low and received her last dose at bedtime. She did not receive her morning dose and was told she would have to wait until the evening for the next dose. Staff interviews revealed that the medication should have been reordered when the supply reached the 'blue line' on the medication card, typically about a week before running out. However, the charge nurse acknowledged that he noticed the medication was running low but did not reorder it in time, citing being busy and overlooking the task. The medication was not available in the facility's emergency kit, and the pharmacy only delivered in the evenings on weekdays. The Director of Nursing (DON) and other staff confirmed that all nurses were trained to reorder medications when supplies were low, but there was no written policy available for medication ordering and reordering. The resident expressed concern about the need for medications to be available when needed, although she reported being okay with her pain at the time. The failure to order the medication in a timely manner resulted in the resident missing a scheduled dose, as documented in the facility records and staff interviews.