Failure to Administer Ordered Medication Due to Unavailable Supply and Access Issues
Penalty
Summary
The facility failed to provide care that met professional standards for one resident by not obtaining and administering carvedilol as ordered by the physician. The resident, who had diagnoses including type II diabetes, dementia, and hypertension, was admitted with a physician's order for carvedilol to be given twice daily for hypertension. Record review showed that the medication was not administered on several occasions because it was not available, as documented in the Medication Administration Record and nursing progress notes. Staff interviews revealed that the carvedilol had been ordered from the pharmacy, but it was not delivered. The Certified Medication Technician reported checking on the medication status daily and attempting to access the emergency kit (eKit) for the medication, but did not have access and had to rely on nurses to obtain it. There was inconsistency among staff regarding access to the eKit, with some nurses able to access it and others losing access if they did not log in regularly. The Director of Nursing confirmed that any nurse could pull medication from the eKit, but if access was lost, another nurse should have been asked to assist.