Failure to Administer Medications as Ordered Due to Unavailability
Penalty
Summary
The facility failed to follow physician's orders by not administering prescribed medications to six residents due to medication unavailability. Multiple instances were documented where residents missed doses of essential medications, including those for diabetes, pain management, constipation, vitamin deficiency, and psychiatric conditions. The Medication Administration Records (MARs) for each resident showed specific dates and numbers of missed doses, with reasons consistently cited as the medications being unavailable. For example, one resident missed several doses of pain medication, insulin, and gastrointestinal medications, while another missed doses of muscle relaxants, diabetes medication, and eye drops. These omissions occurred over several months and affected both newly admitted and long-term residents. Interviews with residents revealed that some were aware of missed doses and reported discomfort or exacerbation of symptoms, such as increased pain or bowel issues. One resident specifically mentioned being told by the DON that their pain medication was given to another resident and described ongoing issues with running out of medications, including muscle relaxers and bowel medications. Other residents either could not recall specific medication issues or believed they were receiving all their medications, despite documentation to the contrary. Staff interviews indicated a lack of awareness regarding the frequency and extent of medication unavailability. Certified Medication Technicians (CMTs) and Registered Nurses (RNs) stated that they typically use emergency kits or reorder medications through the electronic health record system, and denied knowledge of residents running out of medications. The DON and Administrator described processes for monitoring and reordering medications, but were not aware of ongoing issues. The facility did not provide a policy regarding following physician orders or procedures for handling missed doses due to unavailability.