Failure to Provide and Administer Prescribed Medication Due to Lack of Availability and Communication
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered by the physician, specifically a combination tablet of folic acid, vitamin B6, and vitamin B12, prescribed to be administered twice daily. Medical record review showed that the resident, who had multiple diagnoses including irritable bowel syndrome, hypothyroidism, chronic kidney disease, and chronic congestive heart failure, did not receive the morning dose of the prescribed medication on numerous dates in July and August. The Medication Administration Record (MAR) indicated that only the evening dose was consistently administered, while the morning dose was missed on several occasions. Interviews with staff revealed that the prescribed medication was not available in the facility, and the over-the-counter alternative did not match the required formulation, so it was not administered. The LPN could not recall if the physician or pharmacy was notified about the unavailability of the medication. The pharmacist confirmed that the pharmacy did not supply the required medication, and the DON verified that there was no documentation of communication with the physician or pharmacy regarding the missing medication or need for refills. The DON also could not confirm what medication, if any, was being administered in place of the prescribed formula.