Failure to Provide Timely Medication Administration Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered in a timely manner to two residents. One resident, admitted with multiple complex diagnoses including epilepsy and requiring ventilator support, had a physician order for lacosamide to control seizures. The medication was not administered on two consecutive days because the pharmacy required a prescription, and the medication was not available in the facility. Nursing staff notified the nurse practitioner, who contacted the pharmacy, but the medication was still not received before the resident was readmitted to the hospital. Another resident with diagnoses including cerebral palsy, epilepsy, and profound intellectual disability had a physician order for phenobarbital suppositories to be administered three times daily. The medication was not administered for several days because the pharmacy required an updated prescription, and multiple attempts by nursing staff to provide the prescription were unsuccessful. The resident did not receive the medication until the prescription was finally sent electronically and the pharmacy delivered the medication. Facility policy required that all medications be ordered and received in advance, with documentation maintained by the charge nurse and verification by the receiving nurse. Despite these procedures, the facility did not ensure that medications were available for administration as ordered, resulting in missed doses for both residents.