Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered according to physician orders for two residents. One resident, who had a peripherally inserted central catheter (PICC) for intravenous antibiotics due to a urinary tract infection with ESBL resistance and iron deficiency anemia, did not receive their prescribed IV antibiotic on the evening of admission. The medication was not available because it was not ordered in time, resulting in the first dose being missed and not administered until the following day. The resident confirmed that the antibiotic was not given as scheduled upon admission. Another resident with chronic kidney disease and dementia had multiple missed doses of prescribed medications, including potassium chloride for hypokalemia and metoprolol succinate for hypertension. Documentation in the medication administration record indicated that these medications were not administered on several days due to unavailability, with notes stating they were either awaiting delivery from the pharmacy or on order. The medications were, in fact, available in the facility, but nursing staff did not locate them in the medication cart or backup supply. Interviews with facility staff confirmed awareness of the missed doses and revealed that nursing staff did not follow proper procedures to ensure timely medication administration. The facility's policy requires medications to be administered as prescribed and for staff to be familiar with medication locations and ordering processes, but these procedures were not followed, resulting in the deficiencies observed.