Failure to Administer Prescribed Medication Due to Unavailability and Protocol Noncompliance
Penalty
Summary
A resident with diagnoses of bipolar disorder, anxiety, and schizophrenia did not receive her prescribed Lorazepam 1.0 mg at the scheduled 9am and 1pm doses on two consecutive days. The resident noticed the missed doses when she counted her medication and found it short, prompting her to ask the nursing staff, who confirmed that the medication had not been delivered. The resident then requested to file a grievance with the Social Services Director, who assisted her and notified the Assistant Director of Nursing. Interviews with nursing staff revealed that the medication was unavailable, and although facility protocol required staff to retrieve such medications from the emergency box, this was not done. Instead, the nurses either informed their supervisor or contacted the pharmacy about the delivery, resulting in the resident missing her scheduled doses. Documentation confirmed the missed administrations, and facility policy required medications to be administered as ordered by the physician.