Failure to Ensure Availability and Administration of Routine Medications
Penalty
Summary
Facility staff failed to ensure that routine and necessary medications were available and administered as ordered for three residents. For one resident with multiple complex diagnoses including hemiplegia, heart failure, atrial fibrillation, and a history of stroke, there were repeated instances documented in the clinical record where medications such as saline nasal mist, Umeclidinium-Vilanterol inhaler, cholecalciferol, lidocaine patches, and fiber supplements were not available for administration. Progress notes repeatedly indicated that medications were 'awaiting pharmacy delivery,' 'med missing,' or 'med not on cart,' with no evidence that the attending physician was consistently notified or that alternative therapies were arranged as per facility policy. Another resident with Parkinson's disease, diabetes, and a history of CVA had orders for medications including Eliquis, sertraline, and carbidopa-levodopa. Documentation showed that these medications were not available on multiple occasions, with notes such as 'reordered,' 'awaiting pharmacy,' and 'med on order.' Despite the facility's policy requiring notification of the physician and pharmacy when medications are unavailable, there was no documentation that the physician was contacted regarding the unavailability of these critical medications. A third resident with chronic obstructive pulmonary disease, diabetes, and multiple other chronic conditions also experienced repeated unavailability of prescribed medications, including dapagliflozin, Incruse Ellipta, Buspar, and ipratropium. Medication administration records and progress notes over several months indicated that these medications were frequently not available, on order, or delayed due to insurance issues, with no evidence that the medical provider was notified in a timely manner. Interviews with nursing staff revealed inconsistent understanding of the procedures to follow when medications are unavailable, and the interim DON acknowledged that some residents were not entered into the pharmacy's automatic refill program, contributing to the ongoing medication availability issues.