Failure to Provide Ordered Medications and Ensure Timely Pharmacy Delivery
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and administer medications as ordered for a resident admitted with diabetes, hypertension, and heart failure. Upon admission, the resident had 14 scheduled medications ordered by the physician as of 11/5/26. Review of the Medication Administration Record (MAR) showed that on 11/6/26, within 24 hours of admission, the resident received only five of the 14 prescribed medications, three of which were supplements and two over-the-counter medications for pain and allergies. The remaining nine medications, including two diabetes medications, three blood pressure medications, a cholesterol medication, a blood thinner, an antidepressant, and eye drops, were not administered. For each of these missed medications, the Licensed Nurse documented that the medications were not available and that the facility was waiting for pharmacy delivery. The resident also had a physician’s order dated 11/5/25 for dulaglutide, a once-weekly injection to control blood sugar, ordered to be given one time a day with no specific day of the week indicated. Nursing notes on 11/6/25 and 11/13/25 documented that the facility was waiting for the pharmacy to deliver this medication, and notes on 11/27/25 and 12/4/25 documented that the medication was not administered without providing any explanation. Over the five-week admission period, the MAR showed five opportunities to administer dulaglutide, but it was given only twice. The DON stated that all medications should be available within eight hours of admission and that if medications were not available, nurses should have notified the DON or Assistant DON to find a solution. The DON acknowledged that although LNs documented that medications were not available, no staff resolved the issue and the medications were not administered as they should have been. Facility policies required ordering medications from the pharmacy with delivery within eight hours of admission and accurate preparation and administration of medications as ordered.
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