Failure to Provide and Administer Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered to two newly admitted residents. For one resident, multiple medications for conditions including COPD, heart failure, depression, hypertension, hypokalemia, and atrial fibrillation were not given on the first and second days after admission due to the medications not being received from the pharmacy. The resident reported not receiving all prescribed medications, and medical record review confirmed the missed doses. The facility's emergency medication supply did not contain all required medications, and there was no documented communication with a provider regarding the missed doses. For the second resident, essential medications for cardiac conditions, diabetes, hypertension, and infection were not administered on the day of admission because they were unavailable. Progress notes indicated the medications were not on hand, and there was no evidence that a provider was notified about the missed doses. The facility's emergency supply only included a lower dose of one of the required medications. Facility policy required staff to notify a physician and obtain alternative orders when medications were unavailable, but this was not documented in either case.