Failure to Administer Medications as Ordered and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents. For one resident with Alzheimer's disease, heart failure, and generalized anxiety disorder, physician orders specified the application of a lidocaine 4% topical patch to the left hip for 12 hours on and 12 hours off. However, medical record review and staff interview revealed that from August 2024 to March 2025, the resident was signed off for the application of two lidocaine patches daily, resulting in an external patch being on at all times, contrary to the intended order. The DON confirmed that the physician's orders were not transcribed accurately, leading to continuous patch application. For another resident with cerebrovascular disease, narcolepsy, chronic kidney disease, dementia, and dry eye syndrome, there was a physician's order for Rocklatan ophthalmic solution to be administered at bedtime. Review of medication administration records showed that the medication was not administered on multiple occasions due to it not being available. Further investigation revealed that the required prior authorization for the medication had never been sent to the pharmacy. Nursing staff failed to follow up with the pharmacy or notify the provider regarding the unavailability of the medication, as confirmed by the DON. Facility policy required medications to be administered as prescribed and for staff to contact the Medical Director if there were concerns, but this was not followed.