Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for a resident with multiple chronic conditions, including pneumonia, chronic inflammatory demyelinating polyneuritis, neuropathy, chronic pain, and osteoarthritis. Record reviews showed that the resident was admitted with significant pain and required scheduled and PRN pain medications, among other treatments. Despite these needs, the Medication Administration Records (MARs) revealed multiple instances where prescribed medications, including buprenorphine for pain, fish oil, polyethylene glycol, lubiprostone, Bactrim DS, and Metamucil, were not administered on several dates across multiple months. Notably, there were 11 consecutive missed doses of buprenorphine and several other missed doses of various medications. Interviews with facility staff, including the Unit Manager and DON, confirmed that the resident did not receive all scheduled medications on the identified dates. The DON further confirmed that some missed doses were due to waiting for pharmacy delivery, and acknowledged that the facility did not have a policy regarding unavailable medications. The lack of a system or policy to ensure timely medication availability and administration directly contributed to the resident not receiving necessary medications as ordered.