Failure to Administer Ordered Medication Due to Lapses in Medication Management
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including depression, was not administered Mirtazapine as ordered. The resident was cognitively intact and had an active prescription for Mirtazapine 15 mg to be given at bedtime. The Medication Administration Record (MAR) showed that the medication was not given on three specific dates, and there was no documentation in the progress notes explaining the missed doses. The facility's policy requires that if a medication cannot be located, staff should search other areas and contact the pharmacy or use the emergency kit, but there was no evidence these steps were taken. Pharmacy records confirmed that a supply of Mirtazapine was sent to cover the period up to a certain date, with the next supply sent after a gap. During the gap, no doses were removed from the contingency supply, and the pharmacy was not contacted for a refill as per protocol. The facility was unable to provide additional information regarding the missed doses when questioned by the surveyor. This failure resulted in the resident not receiving the prescribed medication as ordered.