F0684

D

Failure to Administer Ordered Medications and Notify Provider of Unavailable Drugs

Chesterfield, Virginia Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Facility staff failed to administer medications in accordance with active physician orders and did not consistently notify the provider when medications were not available for a resident in the survey sample. Review of the clinical record and MAR for this resident showed that on one occasion Hydralazine HCL, ordered for blood pressure management, was not administered, with a nursing progress note stating the medication was unavailable and awaiting refill from the pharmacy. However, review of the facility’s Omnicell content listing indicated that this medication should have been available on-site for staff to administer. On another date, the resident did not receive the ordered dose of diltiazem HCl ER beads (Cardizem), used to treat hypertension and other cardiac conditions, and there was no nursing documentation indicating why the dose was missed or that the provider had been notified.

Further review of the resident’s June MAR revealed no documentation of administration of pantoprazole sodium (Protonix), a proton pump inhibitor, on a specified date, and there were no progress notes explaining the omission or showing that the physician was informed. Interviews with LPNs and nursing leadership showed variation in how staff responded when medications were not available, including differing practices regarding when to contact the provider and how to document missed doses. The facility’s written policy on medication administration required staff to search for ordered medications in multiple locations and contact the pharmacy or use the emergency kit if the medication could not be located, but the documented omissions and lack of provider notification for this resident demonstrated that these steps were not consistently followed.