Failure to Maintain Availability of Ordered Antihypertensive Medication
Penalty
Summary
Surveyors identified that the facility failed to ensure prescribed medications were available for administration, as required by its own "Medication Reordering" policy. That policy stated that acquisition of medications should be completed in a timely manner to ensure timely administration, and that nurses must monitor remaining supply and reorder medications early enough to prevent omissions. During a medication pass observation and interview on 02/18/2026 at 9:36 a.m., an LPN did not have Hydralazine HCL 10 mg on the medication cart or in the medication storage room for a resident. The LPN confirmed that the medication was not available anywhere in the facility at that time. Record review showed the resident had been admitted with diagnoses including essential hypertension and had a current physician order for Hydralazine HCL 10 mg by mouth twice daily, with a start date of 01/06/2025. The Medication Administration Record indicated the last dose of Hydralazine 10 mg was given on 02/17/2026 at 5:00 p.m., and there was no documented evidence that the 8:00 a.m. dose on 02/18/2026 was administered. The LPN confirmed the medication had not been reordered from the pharmacy as of 02/18/2026, despite the ability of any nurse administering medications to reorder it up to seven days in advance to prevent running out. In a subsequent interview, the administrator confirmed that medications ordered by the physician should always be available for administration and that nurses were expected to request refills before supplies were exhausted.
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