F0760

E

Widespread Failure to Obtain and Administer Ordered Medications

Kirkwood, Missouri Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that physician-ordered medications were obtained from the pharmacy and administered as ordered, resulting in numerous missed doses and “drug not available” occurrences for multiple residents. Facility policies required timely faxing and reordering of medications, use of the emergency kit or automatic dispensing unit for first doses, and prompt transcription and implementation of physician orders, including ensuring prompt delivery from the pharmacy. Despite these policies, staff frequently documented medications as unavailable, left blanks or holes on the MARs where doses should have been recorded, and did not consistently ensure that orders were correctly entered when the facility changed electronic medical record (EMR) systems.

One resident with multiple sclerosis, repeated falls, and obstructive sleep apnea had an order for modafinil 100 mg, three tablets once daily, and Glatopa 40 mg SQ every other day. Modafinil was documented as drug not available for 20 of 22 opportunities, and Glatopa was documented as drug not available for 5 of 10 opportunities in one EMR system. After the facility switched to a second EMR, Glatopa was documented as not administered 8 of 9 opportunities, and the modafinil order was incorrectly entered as 100 mg, one tablet, instead of three tablets. A nurse’s note indicated the resident had not received modafinil since admission, and the DON later confirmed the EMR 2 order was incorrect. The pharmacist stated that only two doses of Glatopa (a one-week supply) had been dispensed and that failure to dispense or give modafinil correctly could potentially increase fall risk.

Another resident with muscle weakness and diabetes had an order for tramadol 50 mg twice daily for pain, but the eMAR showed multiple missed doses over nearly two weeks, with staff documenting that tramadol was not administered because it was unavailable. The resident reported not receiving pain medication routinely. A different resident with acute kidney failure, acute respiratory failure, and muscle weakness had orders for tramadol, Bion Tears eye drops, and olopatadine eye drops; the eMAR showed repeated missed doses of all three medications over several days to weeks, with progress notes consistently stating the medications were unavailable. This resident reported not receiving eye drops and stated nurses told them the drops were not available.

A resident with chronic kidney disease, major depressive disorder, and anxiety had an order for midodrine 2.5 mg twice daily and for sodium chloride 0.9% IV infusions twice weekly. After the facility switched EMR systems, there was no physician order or administration documentation for midodrine in the new EMR, and two bags of sodium chloride labeled for the resident were observed sitting on top of the medication room refrigerator, with blank documentation for certain infusion dates. A hospital nurse reported that when this resident arrived at the hospital, their blood pressure was very low and remained low overnight. The DON later stated the midodrine order had not been transferred correctly into the new EMR and that the resident should have received the sodium chloride infusions.

Another resident with chronic pain, diabetes, anxiety, high blood pressure, and a history of healed physical injury had an order for atenolol 50 mg daily, which was documented as not administered for all available opportunities. The same resident had an order for Augmentin three times daily for a urinary tract infection, with multiple doses over several days documented as not administered. The resident stated they had never received atenolol since it was ordered and had not received the antibiotic, and staff told them the antibiotic was on order. A further resident with coronary artery disease, heart failure, diabetes, high cholesterol, anemia, peripheral vascular disease, hypothyroidism, major depressive disorder, and chronic kidney disease had multiple cardiac, anticoagulant, thyroid, and blood pressure medications ordered, including atorvastatin, levothyroxine, metoprolol, midodrine, spironolactone, Eliquis, clopidogrel, and amiodarone. The eMAR showed extensive missed doses for each of these medications, with some documented as medication not available and others simply not given, and only one progress note indicating a call to the pharmacy about spironolactone.

Staff interviews revealed systemic issues contributing to the missed medications. A certified medication technician stated that the facility had recently changed to a new medication ordering system, that the system was “messed up,” and that medications were frequently not given because they had not been ordered properly; the technician also reported not receiving proper training on the new system. An LPN stated that medications should be administered per physician order and that if a medication was unavailable, the nurse should document this and call the physician or pharmacy. The DON stated that holes and blank spots on the MAR meant medications were not given, that staff should check the Pyxis and request STAT delivery if medications were out, and that if a medication was on backorder, the physician should be contacted for a substitute order. The DON also stated that staff were expected to reorder medications timely and notify pharmacy and the physician after one missed dose, rather than after multiple missed doses, which contrasted with the repeated documentation of unavailable medications and numerous missed administrations found in the records.