F0755

D

Failure to Ensure Availability and Timely Administration of Ordered Medications

Bountiful, Utah Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide routine and emergency medications as ordered for two residents, resulting in multiple missed doses due to medications being out of stock or not delivered. For one resident with type 2 diabetes, orthopedic aftercare needs, and an amputation of the left great toe, the medical record showed standing orders for glimepiride 4 mg at bedtime for diabetes, Eucerin Advanced Repair cream twice daily for dry, scaly skin on both lower extremities, and amitriptyline 25 mg at bedtime as an antidepressant. The MAR documented that glimepiride was not administered on multiple dates in September because the medication was not on hand, out of stock, or awaiting refill from the pharmacy. Progress notes repeatedly recorded that the glimepiride was unavailable, reordered, and awaiting delivery, and that staff were unable to give the medication because it was not in stock.

For the same resident, the Eucerin cream was not administered on multiple dates in June and August. Progress notes documented that the cream was out of supply and on order. Additionally, amitriptyline was not administered on two consecutive dates in June. An eMAR note indicated there was “no med,” and a subsequent note documented that the medication was not available. A separate encounter note recorded that the resident sought verification that she was still supposed to receive her amitriptyline dose, and staff verified that the order was still active and that she should be receiving it nightly. Despite this, the MAR and notes show that the medication remained unavailable on at least one of those dates.

The second resident was admitted for post‑operative rehabilitation with IV infusions and had diagnoses including orthopedic aftercare following an amputation, acute osteomyelitis of the right ankle and foot, cellulitis of the right lower limb, and type 2 diabetes mellitus. This resident had physician orders for Piperacillin‑Tazobactam 3.375 g IV every 6 hours and Vancomycin 1 g IV twice daily for infection. The MAR showed that the resident did not receive the ordered Piperacillin‑Tazobactam doses at two scheduled administration times and that the ordered Vancomycin evening dose was not given at the scheduled time but was instead administered several hours later. Nursing documentation stated that the resident was admitted after the scheduled dose time, that none of the prescriptions were faxed to the pharmacy on arrival, that faxes were not going through, and that the Piperacillin‑Tazobactam was not in the emergency kit and had not been delivered from the pharmacy. The resident later reported being very upset about not receiving antibiotics for several hours after they were due and expressed concern about his infection.

Interviews with staff further described the facility’s processes and expectations for medication ordering and availability. An LPN stated that when a medication needed to be refilled, it was reordered in the electronic medical record to alert the pharmacy, and that residents should not go a week without a medication. The LPN also stated that nurses should notify the provider when a resident is out of medication and document those communications. An RN reported that medications should be reordered when there is about one week of supply left and that residents should never run out of medications, emphasizing that it is the nurse’s job to ensure medications are ordered and do not run out. The DON stated that medications should be reordered when there are five days left, that unavailable medications should be communicated to the provider for further direction, and that such issues should be documented and brought to nursing management. Despite these stated expectations, the records for both residents show repeated missed doses and documented unavailability of ordered medications.