Failure to Administer Medications as Ordered Due to Lack of Availability and Tracking
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including COPD, morbid obesity, asthma, atrial fibrillation, heart failure, anxiety, depression, chronic kidney disease, insomnia, and sleep apnea, was not consistently administered prescribed medications as ordered by the physician during April 2025. The resident, who was cognitively intact, reported that staff frequently failed to provide both prescription and over-the-counter medications, including her antidepressant, pain medication, and inhalers. Review of the medication administration record confirmed that several medications were missed on multiple dates throughout the month, and progress notes indicated these omissions were due to medication unavailability. Staff interviews revealed a lack of a formal system to track and ensure the availability of over-the-counter medications, with communication about shortages occurring only after medications were already missing. The central supply coordinator and unit manager both acknowledged the absence of a tracking system, and the DON stated she relied on staff communication to maintain medication availability. The pharmacy manager confirmed that all medications were refilled as ordered and could not explain the lapses, while the primary care physician was not fully aware of the missed doses. Documentation did not consistently show that the physician was notified when medications were not administered.