F0755

D

Failure to Ensure Timely Availability of Routine Medications

Evansville, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that pharmaceutical services provided physician-prescribed routine medications as ordered, resulting in missed doses for two residents. One resident with diagnoses including depression and anxiety had a physician order for Ativan 1 mg three times daily starting in December. Review of the January Medication Administration Record (MAR) showed that the 2:00 p.m. and 8:00 p.m. doses on one day were not documented as administered. Nursing progress notes for that day documented that the pharmacy was waiting on a new prescription and that the pharmacy was aware of the need for the medication, and the resident reported she had recently not received her routine antianxiety medication because the facility had run out.

Another resident, with diagnoses including vitamin deficiency, cerebral palsy, and reduced mobility, had physician orders for a daily multivitamin, daily vaginal lubricant (Replens gel), and Chlorzoxazone 500 mg four times daily. The January MAR showed multiple days when these medications were not administered. The multivitamin was not given on one day; Replens gel was not given on four separate days; and Chlorzoxazone was not given on multiple consecutive and nonconsecutive days. Nursing notes repeatedly documented that these medications were pending pharmacy arrival, on order, not available, or waiting on pharmacy delivery, and that the facility was out of Replens and had reordered it. An RN stated it was the nurse’s responsibility to reorder medications before they ran out. The facility’s pharmaceutical services policy stated that residents may use a pharmacy of their choice as long as the pharmacy refills prescription drugs when needed to prevent interruption of drug regimens.