Failure to Obtain and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were obtained from the pharmacy and administered as ordered for a resident with multiple complex medical conditions, including epilepsy, cognitive communication deficit, a need for assistance with personal care, and a history of encephalitis. Record review showed that on several occasions, the resident did not receive prescribed medications such as clobazam, enoxaparin sodium injection, and phenobarbital because the facility did not have these medications available from the pharmacy. Nursing staff documented these missed doses on the Medication Administration Record (MAR), and the physician was not notified when the medications were unavailable. The Director of Nursing confirmed that the medications were not available from the pharmacy at the times indicated. The facility's policy stated that the pharmacy would supply and deliver needed medications, but this was not followed in these instances. The deficiency was identified during a review of the resident's medical record and MAR, as well as through staff interviews, and was investigated under multiple complaint numbers.