Failure to Ensure Timely Administration of Ordered Medication Due to Supply Lapse
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple diagnoses, including spinal stenosis, dementia, and chronic obstructive pulmonary disease. The resident had a physician's order for baclofen 5 mg to be administered orally three times daily. However, the medication was not administered as ordered on four occasions over two consecutive days because the supply had run out and was pending arrival from the pharmacy. Documentation in the Medication Administration Record (MAR) and progress notes confirmed that the baclofen was not given at the scheduled times, and staff interviews revealed that the medication was not available in the emergency medication kit in the required dosage. The nurse involved stated that when medications were unavailable, she would check the emergency supply and notify the pharmacy and DON, but in this instance, the physician was not notified, and the resident missed several doses. The DON was only made aware of the issue after the resident reported it, and upon investigation, found that the medication had not been administered due to lack of supply and that the pharmacy had previously delivered a 30-day supply earlier in the month. Further review with the pharmacy confirmed that the medication had been delivered as scheduled, but the resident ran out of the medication several days early. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this case. The administrator stated that staff were expected to notify management immediately if a medication was unavailable so it could be reordered and administered by the next scheduled dose, but this protocol was not followed, resulting in missed doses for the resident.