Failure to Provide Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered by the physician for one resident. Clinical record review, policy review, and interviews revealed that a resident with moderately impaired cognition, multiple diagnoses including hypertension, diabetes, depression, and significant oral health issues, did not receive prescribed Nystatin suspension for oral thrush on multiple occasions. The care plan required administration of antifungal medication and monitoring for oral and cognitive symptoms, but progress notes documented numerous missed doses due to the medication not being available in the facility. The resident confirmed not receiving the medication as ordered. Interviews with the ARNP and the Director of Nursing confirmed that the expectation was for staff to ensure medication availability, administer as ordered, and notify the pharmacy or physician if medications were unavailable or missed. The ARNP observed ongoing symptoms of thrush during assessment, attributing this to the missed medication doses. Facility policy required timely medication administration and consultation with a licensed pharmacist, but these procedures were not followed, resulting in the deficiency.