Failure to Provide Ordered PRN Muscle Relaxant Due to Medication Unavailability
Penalty
Summary
Surveyors determined that the facility failed to provide necessary pharmaceutical services when a resident did not receive a prescribed PRN muscle relaxant for an extended period. The resident reported during an interview that she had routinely taken Cyclobenzaprine HCl 10 mg at bedtime to relieve muscle spasms but had not received it for the past two weeks, and staff told her the medication was not available from the pharmacy. A staff member confirmed that the medication was not available in the medication cart to administer to the resident. Review of the physician’s order dated November 10, 2025, showed an active order for Cyclobenzaprine HCl 10 mg, 1 tablet by mouth every 8 hours as needed for muscle spasms. Review of the December 2025 MAR showed the medication was administered 15 times, with 11 of those doses given at bedtime between 8 p.m. and 10 p.m., and the last recorded administration on December 28, 2025. Further review of the January 2026 MAR through January 26, 2026, revealed that the resident did not receive any doses of Cyclobenzaprine HCl for the entire month, indicating that the ordered PRN medication was not provided after December 28, 2025. This lack of availability and administration of the ordered medication, despite an ongoing physician order and prior routine use by the resident, formed the basis of the cited deficiency under 28 Pa. Code 201.14(a) and 211.9(a)(1)(f)(2)(4)(k) related to pharmacy services.
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