Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the timely availability and administration of prescribed medications for multiple residents, resulting in missed doses and medication errors. One resident with depression and a history of stroke did not receive the antidepressant Paxil from 5/31/2025 to 6/04/2025 due to a lapse in pharmacy deliveries, as confirmed by pharmacy records and staff interviews. The same resident also experienced a gap in the availability of Sumatriptan, a medication for migraines, which was not available for several days and had to be supplied by a family member after insurance issues delayed pharmacy delivery. Staff and the DON acknowledged that the medications were not available as required, and the facility's own policies for medication reordering and handling unavailable medications were not followed. Another resident with chronic kidney disease and heart failure was prescribed Hydralazine for hypertension, with specific instructions to hold the medication if systolic blood pressure was below 120 mmHg. However, the MAR showed that Hydralazine was administered on multiple occasions when the resident's systolic blood pressure was below the prescribed threshold. The nurse involved confirmed that the medication should have been held according to the physician's order, and the facility's policy required adherence to such parameters. A third resident with chronic pain and polyneuropathy was prescribed senna for bowel management, with orders to hold the medication if the resident had loose stools. Despite documentation of loose stools on several days, senna was administered as scheduled, and the resident reported not ingesting the medication after realizing its purpose. The nurse admitted to administering senna despite the resident's report of loose stools, and the ADON confirmed that this was not in accordance with the physician's order. Additionally, another resident did not receive ergocalciferol as prescribed because the medication was not available in the facility at the scheduled time, which was acknowledged as a medication error by the nurse and DON.