Failure to Ensure Timely Availability of Medications for Resident
Penalty
Summary
Facility staff failed to ensure that medications were available for administration to a resident, resulting in the resident not receiving a prescribed medication as ordered. Specifically, a resident reported frequent issues with medication availability, including pain medication. Review of the resident's clinical record and medication administration record (MAR) revealed that a scheduled dose of Fluticasone Propionate Suspension was not administered because it was not available. The MAR indicated the medication was 'on order,' and this was confirmed by both the unit manager (RN) and the director of nursing (DON) during interviews. The staff acknowledged the importance of timely medication administration and described the process for ordering medications when supplies are low. Facility policy requires that when a medication is unavailable, the nurse must notify the provider, discuss alternatives, activate the backup pharmacy process if needed, and document all notifications. The review found that the medication was not available as ordered, and the resident, as well as the provider and responsible party, should have been informed according to policy. The deficiency was confirmed through resident and staff interviews, clinical record review, and facility documentation.