Failure to Ensure Medication Availability and Administration
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for two residents. For one resident, multiple medications including a fentanyl transdermal patch for pain, Flomax for urinary retention, levofloxacin as an antibiotic, and zolpidem tartrate for sleep were not available on several occasions as documented in the Medication Administration Record. The absence of these medications was confirmed through observation of the medication cart, which lacked the required narcotic patches and documentation, and through interviews with nursing staff who were unaware of the missing medications. The Director of Nursing and a registered nurse also stated they were not aware of the unavailability of these medications and noted that the new automated medication dispensing system did not have narcotics available for supply. A second resident did not receive several critical medications, including amiodarone, amlodipine besylate, metoprolol succinate ER, Keppra, and Eliquis, as ordered during her stay. The resident’s family member reported that medications were not available upon admission, and the Director of Nursing confirmed she had not been informed of the missed doses. Review of facility policy revealed there was no procedure in place for when a medication was not available, and the pharmacy contract indicated that drugs and supplies should be provided as required, including after-hours emergency deliveries. Despite these provisions, the facility did not ensure medication availability, and staff did not report the missing medications to nursing leadership.