Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to administer medications as ordered by the physician for one resident with diagnoses including COPD, stroke, and dementia, who had moderate cognitive impairment. Medical record review showed that the resident did not receive prescribed doses of Rivaroxaban 20 mg on four separate occasions in May 2025 due to the medication being out of stock or unavailable. Documentation indicated that the pharmacy was notified and reorders were sent, but there was no evidence the resident received the missed doses. The facility's policy requires medications to be administered as ordered and in accordance with standards of practice, but this was not followed in these instances.