Failure to Provide Prescribed Medication Due to Ordering Lapse
Penalty
Summary
The facility failed to provide prescribed medication to a resident with a diagnosis of anxiety disorder. The resident was admitted with an order for alprazolam 0.5 mg at bedtime for anxiety. Documentation in the medication administration record (MAR) showed that the medication was not administered on multiple occasions, with staff using a code indicating 'other, see progress notes.' Progress notes from several LPNs consistently indicated that the alprazolam was either not available, not in stock, or still awaited from the pharmacy. The pharmacy delivery records showed no evidence that the medication was received for the resident during the relevant period. Interviews with nursing staff revealed that they were aware the medication was not available and that it had not been delivered, but they did not take further action beyond waiting for the medication. One LPN stated she did not contact anyone and simply waited for the medication. The pharmacist confirmed that the pharmacy never received an order for alprazolam for the resident, and the Director of Nursing Services stated the order was never faxed to the pharmacy. The Executive Director stated that nurses were expected to follow up with the pharmacy and report missing medications to the DNS, but this did not occur.