Failure to Provide Ordered Iron Supplement Due to Medication Unavailability and Cart Transfer Error
Penalty
Summary
The facility failed to ensure a resident received a routinely ordered medication when a prescribed iron supplement was not available or administered as ordered. A resident admitted with multiple diagnoses, including a right humerus fracture and iron deficiency anemia, had a physician order for Ferrous Gluconate 324 mg by mouth once daily for supplementation. During a medication pass observation on 1/7/26 at 9:08 AM, the medication aide (MAC #1) preparing the resident’s medications reported that the Ferrous Gluconate was not available in the facility. At 9:10 AM, MAC #1 stated that the physician’s order had been in place since 12/24/25, but the medication had not been administered because it had not been available. On 1/8/26 at 12:38 PM, the DON reported that the facility had obtained the Ferrous Gluconate on 1/1/26, but after the resident was moved to a different room, the medication was not transferred to the new medication cart for nursing staff to administer, resulting in continued missed doses despite the medication being on site.
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