Failure to Obtain and Administer Ordered Medications for Two Residents
Penalty
Summary
The facility failed to ensure timely receipt and administration of physician-ordered medications, resulting in multiple missed doses for two residents. For one resident with diagnoses including lung disease, schizophrenia, anxiety, bipolar disorder, insomnia, and depression, the physician ordered cariprazine 4.5 mg once daily upon the resident’s readmission. The order was verified and faxed to the pharmacy, and the medication appeared on the MAR; however, documentation throughout late January and February repeatedly showed the drug as “on order” or “unavailable,” with no evidence that the medication was actually administered. The January MAR reflected 7 of 7 missed administration opportunities, and the February MAR showed 24 of 28 missed administration opportunities for cariprazine. Progress notes for this resident documented behavioral issues during the same period, including difficulty sleeping, frequent use of the call light, yelling that disturbed other residents, inability to be easily redirected, and a resident-to-resident altercation that led to psychology and psychiatry consults. Despite the ongoing unavailability of the antipsychotic medication, there were no documented notifications to the physician regarding the missed doses. A pharmacy representative later stated that the pharmacy had not received a prescription for cariprazine from the facility in January following the resident’s readmission and that the next documented dispensing of the medication did not occur until March, when a 14‑day supply was sent. For a second resident with alcoholic cirrhosis and hepatic encephalopathy, the MAR contained an order for rifaximin 550 mg twice daily for 14 days, but there was no documentation that the medication was administered for the entire ordered period. The pharmacy representative reported that rifaximin was not sent because it required a $1600 out‑of‑pocket payment and was not covered by the resident’s health plan, and that payment from either the facility or the resident was needed. A nurse practitioner stated that nursing staff had informed them that the medication was not covered and asked about a less expensive alternative; the nurse practitioner responded that the rifaximin needed to be dispensed and was not informed that the medication was not being administered. The administrator later stated he was unaware the resident had not received rifaximin and that, in general, staff were expected to notify leadership about missing medications rather than continue to document non‑administration.
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