Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
Facility staff failed to provide ordered medications for a resident, specifically niacin and oxycodone-acetaminophen, as prescribed by the medical provider. The clinical record review showed that the resident had active orders for oxycodone-acetaminophen for pain management and niacin as a supplement. The medication administration records indicated missed doses of both medications over several days, with documentation codes referencing unavailability and progress notes explaining that the medications were not on hand, were in transit, or awaiting delivery from the pharmacy. The emergency medication supply (Omnicell) did not contain the required strength of oxycodone-acetaminophen or niacin. Interviews with nursing staff revealed that when medications were not available, they notified the provider and responsible party, and documented the situation in the medical record. Staff explained that over-the-counter medications like niacin were typically ordered through a supply company with less frequent deliveries, and that the pharmacy required an authorization form to dispense such medications. Delays in returning the authorization form contributed to the delay in obtaining niacin for the resident. The pharmacy confirmed that they did not receive the necessary authorization to dispense niacin until several days after the initial order, resulting in a gap in administration. Facility policy required staff to search for missing medications, contact the pharmacy, and use the emergency kit if necessary. The policies also required provider notification and documentation when medications were unavailable. Despite these policies, the resident did not receive the ordered medications as scheduled, and there was a lack of documentation explaining the hold on niacin for certain days. The deficiency was identified through interviews, record reviews, and review of facility documentation, which confirmed that the facility did not have the medications available for administration as ordered.