Failure to Administer Prescribed Anticoagulant Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering the prescribed anticoagulant medication, Eliquis 5mg BID, over a four-day period. The medication was not given from 01/03/2025 to 01/06/2025 because it was unavailable, and no refill was requested by the clinical staff. Both the LVN and RN involved documented the medication as unavailable but did not notify the Director of Nursing (DON) or the physician about the missed doses or the need for a refill. The DON was only made aware of the missed doses after being informed by a federal government agent during a record review on 01/17/2025. The resident involved had significant medical conditions, including paroxysmal atrial fibrillation, atherosclerosis, venous insufficiency, and chronic heart failure, and was dependent on staff for activities of daily living with severe cognitive impairment. The resident's care plan and physician orders specifically required the administration of Eliquis to manage the risk of blood clots associated with his cardiac conditions. Despite clear protocols for medication administration and refills, the staff did not follow procedures to ensure the resident received his prescribed medication, nor did they escalate the issue when the medication was not available. Interviews with the involved nursing staff revealed that neither took steps to notify supervisory staff or the physician about the medication shortage, and both relied on documentation or informal communication with colleagues rather than following established protocols. The DON confirmed that she was not notified of the issue and that the facility had procedures in place for medication refills and emergency medication access, which were not utilized. The failure to administer the prescribed anticoagulant as ordered constituted a deficiency in pharmaceutical services for the resident.