Missed Doses of Anticoagulant and Anticonvulsant Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that ordered medications were administered as prescribed, resulting in missed doses of significant medications for two residents. One resident with a history of pulmonary embolism, diagnosed on 11/4/25, had an order for enoxaparin 100 mg subcutaneously twice daily starting 1/2/26 to treat and prevent blood clots. The January MAR shows this resident did not receive the PM dose on 1/2/26, both AM and PM doses on 1/19/26, the PM dose on 1/20/26, and both AM and PM doses on 1/26/26. The administration notes for these dates document that the medication was "on order." The resident reported that the facility was constantly running out of her medications and that she had missed multiple doses, and the nurse practitioner confirmed that the resident was on enoxaparin to prevent additional blood clots and to keep the previous clot from worsening, and that it was important she receive the doses as ordered. Another resident with a seizure disorder had an order for levetiracetam 500 mg, three tablets twice a day as an anticonvulsant. The January MAR shows this resident did not receive either the AM or PM dose on 1/20/26 and did not receive the AM dose on 1/21/26, with administration notes indicating the medication was not available. The nurse practitioner stated that the resident is on levetiracetam to prevent seizures, that it should be given as ordered, and that missing too many doses could result in a seizure. The nurse practitioner also stated that if a medication is not available, staff should call her for direction, and she was not aware that this resident had missed any doses. The DON stated that all medications should be administered as ordered, that medications should be reordered when there is a 2–3 day supply remaining, and that residents should not have to go without their ordered medications. The facility’s Medication Administration Policy, revised 9/1/24, directs staff to reorder medications from the pharmacy when there is a 2–3 day supply remaining.
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