Failure to Provide Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that routine medications were supplied and administered as ordered for a resident. Specifically, a resident with multiple complex medical diagnoses, including chronic kidney disease, diabetes, sepsis, and other serious conditions, had a physician's order for daily Magnesium Gluconate 250 mg due to hypomagnesemia. Review of the electronic medication administration record (MAR) showed that the resident did not receive several doses of this medication on multiple dates because it was not available in the facility. This was confirmed by both the MAR and the Director of Nursing (DON), who verified the missed doses. Facility policy requires that medications and related products are received from the pharmacy on a timely basis and that accurate records of medication orders and receipt are maintained. Despite this policy, the resident experienced repeated missed doses of the ordered medication over a period of weeks, as documented in the MAR and verified by staff interview. The deficiency was identified during a review of pharmacy services and was investigated under two complaint numbers.