Failure to Provide and Administer Correct Medications
Penalty
Summary
The facility failed to provide ordered medications and administer the correct medication to two residents. One resident with a history of stroke, heart failure, and atrial fibrillation did not receive her prescribed doses of diltiazem (an extended-release cardiac medication) and duloxetine for depression because the pharmacy rejected the refills. The nurse on duty borrowed duloxetine from another resident and substituted regular diltiazem from a different resident, administering multiple tablets to approximate the prescribed dose. The nurse was inconsistent in reporting the number of tablets given and acknowledged that the medications were not the correct formulation. Facility policy prohibits administering medications prescribed for one resident to another and requires staff to notify the Director of Nursing if medications are unavailable or rejected by the pharmacy. Another resident with diagnoses including dysuria, urinary tract infections, and kidney cancer did not receive her prescribed mirabegron for incontinence on multiple occasions, as documented in the Medication Administration Record. The nurse confirmed the medication was not available and had not checked the emergency supply. The resident was not notified about the missing medication and was unsure if she was still receiving it, though she continued to experience symptoms of overactive bladder. The Director of Nursing stated she was not informed of the pharmacy rejection and could not determine the last day the resident received the medication. The facility's failure to ensure the availability and correct administration of medications, as well as the lack of communication and adherence to policy regarding medication shortages and pharmacy rejections, resulted in residents missing essential doses and receiving medications not prescribed to them. These actions directly violated facility policy and the standard of care for medication administration.