Failure to Provide Ordered Medication Due to Unavailability and Lack of Reporting
Penalty
Summary
The facility failed to ensure that a resident received their routine medication, Brivaracetam 75mg oral tablet, as ordered by the physician. According to the Medication Administration Record (MAR), the medication was not administered for several days, with various codes such as '9' (other, such as medication not available), '2', and 'H' (on hold) documented for multiple scheduled doses. There was also a lack of documentation for one of the scheduled doses. The facility's policy requires that any discrepancies related to medication orders be corrected and reported to the nurse manager, but this was not done in this case. Interviews with the Director of Nursing (DON) and an LPN confirmed that the medication was not available and was not administered for several days. The DON also confirmed that there were no progress notes documenting the reason for the missed doses, and that staff did not report the medication discrepancy to her as required by policy. The medication was only issued to the facility by the pharmacist several days after the start date of the physician's order, resulting in the resident missing multiple doses.