Failure to Administer and Communicate Unavailable Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications as ordered for five residents. Multiple medications, including Dapagliflozin Propanediol, Levothyroxine, Acetylcysteine Solution, Eliquis, Memantine HCI, Farxiga, Folic Acid, Pravastatin Sodium, Alendronate Sodium, Sodium Chloride, Linagliptin, Calcium 600 + D, Rifaximin, Symbicort Inhalation Aerosol, Aspirin, Colace, Latanoprost Ophthalmic Solution, Lidocaine External Patch, Prenatal Vitamin, Calcium Antacid Chewable, Vitamin C, Advanced Probiotic, Lisinopril, and Amoxicillin, were not administered to residents as ordered by their physicians. Documentation in the Medication Administration Records (MARs) frequently indicated that medications were not given due to unavailability or pending delivery, with staff using a code to denote this status and referencing nurse's notes for further explanation. Interviews with nursing staff and facility leadership revealed that although staff were trained to notify physicians and nursing supervisors when medications were unavailable, this notification did not consistently occur. Several nurses admitted to not informing physicians when medications were not administered due to lack of availability, despite being aware of the requirement to do so. The Medical Director and attending physicians confirmed they were not notified about missed doses, and expressed that they expected immediate notification in such cases. In some instances, medications were delayed due to pending cost approval or issues with the pharmacy's formulary, but these delays were not communicated to the prescribing practitioners. The affected residents had complex medical histories, including conditions such as esophageal cancer, heart failure, diabetes mellitus, non-Alzheimer's dementia, osteoporosis, chronic kidney disease, hepatic encephalopathy, atrial fibrillation, Alzheimer's disease, and glaucoma. The failure to administer prescribed medications and to promptly consult with physicians or nurse practitioners when medications were unavailable was documented for each resident. The MARs and nurse's notes consistently showed missed doses over multiple days, with staff citing medication unavailability as the reason, but without evidence of timely physician notification or alternative arrangements to obtain the medications.