Failure to Ensure Medication Availability and Administration Due to Ineffective QAPI
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems related to medication availability and administration. During a survey, it was observed that two residents did not receive their prescribed medications because the medications were not available on the medication cart or in the facility's emergency medication supply (Omnicell). In one instance, a resident did not receive Zoloft, an antidepressant, because it had not arrived from the pharmacy and was not available in the Omnicell. In another case, a resident did not receive the correct dose of Coreg, a medication for heart failure, because the required dosage was not available on the cart or in sufficient quantity in the Omnicell. Interviews with nursing staff and facility leadership revealed that the expectation was for nurses to reorder medications from the pharmacy seven days before running out, and to check the Omnicell or contact the pharmacy if medications were not available. However, these procedures were not followed, resulting in missed medication doses. The Director of Nursing and the Administrator acknowledged that their QAPI plan was limited in scope, focusing only on thyroid medications, and did not address broader issues with medication availability, leading to the deficiencies observed.