Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
Facility staff failed to have five ordered medications available for administration to one resident on 5/4/25. During closed record review, the resident’s MAR for May 2025 showed that on 5/4/25 Fluticasone Propionate nasal spray, Vitron-C, Budesonide-Formoterol inhaler, two doses of Buspirone HCL, and Hydralazine HCL were all coded with “9,” which the MAR legend defined as other/see nurse notes. Nursing progress notes for that date documented that each of these medications was “not available.” Physician orders confirmed that all five medications had active orders on that date. The MAR also documented that the resident’s blood pressure on 5/4/25 was 197/103, and the ordered Hydralazine, used to treat elevated blood pressure, was not administered because it was not available. Interviews with nursing staff and review of facility documentation further described how the deficiency occurred. One LPN stated that when a medication is not available, she checks whether it has been ordered, orders it if needed, checks the Omnicell, and if the medication is not STAT, waits for it to arrive from the pharmacy while documenting in the chart and informing the oncoming nurse and administrator. Another LPN reported that she checks the Omnicell and then calls the provider if the medication is not available, documenting the provider’s intervention. The ADON stated that if a medication is not available, staff notify nursing leadership and the physician, obtain an order to hold the medication until it is received, and call the pharmacy if it is not in the Omnicell. Review of the Omnicell contents list showed that, of the five medications not administered on 5/4/25, only Hydralazine 25 mg was stocked in the Omnicell. The facility’s medication administration policy directed staff to search other areas and contact the pharmacy or use the emergency kit if a medication with a current order could not be located, but the record showed the medications were simply documented as not available and not given.
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