Failure to Ensure Availability and Administration of Prescribed Medications
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available and administered as ordered for two residents. For one resident with sepsis, anemia of chronic disease, and joint pain, multiple doses of Daptomycin, Epoetin Alfa-epbx, and Pregabalin were not administered on several dates in February and March. Documentation in the electronic medication administration record (eMAR) indicated that medications were either not available, on order, or awaiting delivery from the pharmacy. Progress notes reflected missed doses due to unavailability, and staff interviews confirmed that when medications were not found in the medication cart or Omnicell, the pharmacy was contacted, and the physician was to be notified if a medication was not given. Another resident with schizophrenia and an enlarged prostate did not receive multiple doses of Ziprasidone and Flomax over several dates from July through September. Review of medication administration records showed missed morning and bedtime doses of Ziprasidone and daily doses of Flomax, with staff confirming that these medications were not available in the Omnicell and were not administered as ordered. The facility's policy required medications to be administered as ordered and in accordance with professional standards, but the records and staff interviews demonstrated that this was not consistently achieved.