Failure to Administer Medications as Ordered Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for two residents. For one resident with multiple diagnoses including a fractured femur, osteoarthritis, anxiety, schizoaffective disorder, and venous thrombosis, several prescribed medications such as Senna, Cefuroxime Axetil, Eliquis, Risperidone, and Methocarbamol were not administered upon admission due to the medications not being available. Documentation in the Medication Administration Record (MAR) and nurses' progress notes confirmed that these medications were missed, and the provider was notified of the missed doses, but no new orders were received. Additionally, the resident received only nine out of ten ordered doses of Cefuroxime Axetil. Another resident with a history of spondylolisthesis, chronic pain, and cervical disc disorder did not receive multiple doses of Lyrica (pregabalin) as ordered for nerve pain. The MAR and nursing notes indicated that the medication was not available on several occasions, resulting in missed doses. The resident reported experiencing neck pain and confirmed that the facility ran out of his medication for six doses during the previous week. The DON confirmed the missed doses upon review of the MARs for both October and November.