Failure to Administer Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice for one resident, resulting in missed doses of prescribed medications due to unavailability. Specifically, the resident was not given metformin, enoxaparin, and nystatin powder as ordered by the physician. The Medication Administration Record (MAR) showed that enoxaparin was not administered on two occasions, nystatin powder was not given on one occasion, and metformin was missed for two doses, all due to the medications not being available in the facility at the required times. Interviews with nursing staff and the Director of Nursing (DON) revealed that the facility's process required nurses to reorder medications when there were two to three days of doses remaining. However, the missed doses occurred because staff did not reorder the medications in a timely manner, leading to a disruption in the resident's medication regimen. Both the DON and a Licensed Vocational Nurse (LVN) confirmed that it was not acceptable to wait until medications were depleted before reordering, and that the expectation was to maintain an adequate supply to avoid missed doses. The resident involved had a history of cerebral infarction, diabetes, seizures, and aphasia, and was assessed as cognitively intact. The facility's policy required medications to be administered as ordered and within a specific time frame, and professional references emphasized the importance of timely administration to maintain therapeutic effectiveness. The failure to follow these procedures resulted in the resident not receiving critical medications as prescribed.