Failure to Provide Ordered Antimicrobial Medication Due to Breakdown in Medication Acquisition and Communication
Penalty
Summary
The facility failed to ensure the availability and administration of a prescribed antimicrobial medication, Rifampin, for a resident with a history of surgical wound infection and multiple bacterial infections. Despite an active physician order for Rifampin to be administered twice daily, the medication was not available or given to the resident from 8/8/2025 to 8/20/2025. The medication administration record showed that no doses were received during this period because the medication was listed as 'on order.' Nursing staff were not aware of the medication's unavailability until several days after the resident had already missed multiple doses. The pharmacy ultimately informed the facility that the medication would not be dispensed due to a possible drug interaction, but this was only communicated after the resident had missed 12 doses. Interviews revealed that the licensed vocational nurse (LVN) was first notified of the missing medication late in the process and was unable to obtain it due to the pharmacy being closed. The Director of Nursing (DON) described a process for reporting and following up on unavailable medications, but this process was not effectively implemented in this case. The resident, who had moderate cognitive impairment and was not aware of the missed medication, was at risk due to the lack of timely communication and follow-up regarding the medication's availability. The facility was unable to provide a policy on medication availability when requested by the surveyor.