Failure to Provide Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered by the physician for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, heart failure, and pressure injuries. Review of the resident's medical record and Medication Administration Records (MAR) revealed that several medications, including Calcitriol, Sevelamer, Diphenhydramine-Zinc Acetate cream, and Brimonidine Tartrate Ophthalmic solution, were not administered on multiple occasions as scheduled. The missed doses occurred over several days, and the medications were not available for administration during those times. An interview with the Director of Nursing confirmed that the medications were not available as required. Facility policy states that medications are to be administered in an accurate, safe, and timely manner, but this was not followed in the case of this resident. The deficiency was identified through closed record review, interviews, and policy review, and it affected one resident out of three reviewed for medication availability.