Failure to Ensure Availability and Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for two residents. One resident was admitted with physician orders for D‑Mannose 500 mg, four capsules by mouth three times daily, and Simvastatin 40 mg once daily. Over several days following admission, the resident received no doses of D‑Mannose and missed doses of Simvastatin on two days. During a morning medication pass, an RN stated that the D‑Mannose was not available because it had not been received from the pharmacy and was not in the stock medication cart, and also confirmed that Simvastatin had not been available on prior days. The MAR and progress notes documented that these medications were not given because they were unavailable or awaiting pharmacy delivery, despite facility policy requiring use of stock medications and STAT pharmacy delivery when medications are not on hand. Another resident was admitted with hospital discharge orders for carbidopa‑levodopa to be given multiple times daily for Parkinson’s disease and Pravastatin for cholesterol control. The MAR showed that the resident did not receive an evening dose of carbidopa‑levodopa on the day of admission and did not receive Pravastatin on the first two days. The DON reported that the nurse on duty confirmed the resident’s wife brought in and gave one dose of carbidopa‑levodopa, but the nurse did not administer the bedtime dose, even though carbidopa‑levodopa was available in the facility’s stock medication cart. The DON also stated that Pravastatin should have been obtained from the pharmacy and administered but was not. A nurse later confirmed with the pharmacy that carbidopa‑levodopa was available in the stock system while Pravastatin was not, and explained that if medications were not available in the stat safe or stock, they should contact the NP for a stat order and obtain the medication from a local pharmacy or through the family.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.