Failure to Administer Medications as Ordered Due to Pharmacy Supply Issues
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents. For one resident with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease, there was a physician's order for Renvela 800 mg once daily. Review of the Medication Administration Records (MAR) over several months revealed that Renvela was not administered on numerous dates, and progress notes indicated the medication was not available from the pharmacy on those occasions. The Director of Nursing confirmed these missed administrations. For another resident with a history of cerebral infarction, hemiplegia, hemiparesis, anxiety disorder, and moderate cognitive impairment, multiple medications were not administered as ordered on several dates. These included Metoprolol, Pramipexole, Doxepin, Citalopram, Divalproex, Atorvastatin, and Apixaban. Nurse notes consistently documented that the medications were not available or were awaiting arrival from the pharmacy. The resident confirmed not receiving medications over a weekend, and the Director of Nursing verified the missed doses due to pharmacy supply issues. Facility policy requires that medications be administered in accordance with prescriber orders and within required time frames. However, the documented failures to provide ordered medications as scheduled, due to unavailability from the pharmacy, resulted in noncompliance with this policy for the two residents identified in the report.