Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, diabetes, dementia, and hemiplegia did not receive their ordered artificial tears for 14 days, missing 55 doses. The September Medication Administration Record showed the medication was not administered from 9/10/25 through 9/24/25. There was no documentation in the resident's progress notes indicating that the physician was notified about the unavailability of the artificial tears or that the resident was not receiving the medication as ordered. Staff interviews revealed that the facility was aware the artificial tears were on back order with the stock supply distributor, but the medication was not ordered through the pharmacy until 9/24/25, when a nurse called the pharmacy and the medication was delivered later that day. The facility's policy instructed nurses to report supply deficiencies to the DON but did not provide guidance on notifying the prescriber or pharmacist when medications were unavailable. The DON confirmed that the physician should have been notified when medications were not received.