Failure to Obtain and Administer Ordered Medications for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered medications were available and administered as prescribed for one resident on the night of admission. The facility’s Medication Availability form, identified by the Nurse Consultant as the protocol for missing medications, directs staff to check the Emergency Medication Kit (E Kit), call the pharmacy for an estimated delivery time, notify a supervisor, and, if the delay is greater than four hours, call the physician for a plan to address the situation. Record review of the electronic Medication Administration Record (eMAR) for January 2026 showed that on the night of admission, the resident had physician orders for terazosin 1 mg at HS for essential hypertension, dabigatran 150 mg twice daily at HS for paroxysmal atrial fibrillation, and morphine sulfate 30 mg twice daily for pain related to rheumatoid arthritis. All three medications were documented with code 7 (Other/See Progress Notes), indicating they were not administered as ordered. Progress notes dated that night at 11:48 PM contained only the entry "awaiting medications" with no further documentation that the medications were obtained or given in accordance with the facility’s protocol. Interview with an LPN confirmed that, for new admissions, medication orders are transmitted to the pharmacy and that if medications are not available, staff may obtain them from the E Kit or contact the pharmacy, including backup or emergency pharmacy, to secure the medications. The LPN stated that failure to administer the resident’s prescribed medications could result in adverse outcomes. Review of the eMAR and interview with the DON confirmed that the three ordered medications were not administered and that staff did not follow the facility’s protocol for obtaining unavailable medications. Admission records showed the resident was admitted with essential hypertension, paroxysmal atrial fibrillation, and rheumatoid arthritis, requiring ongoing physician-ordered medication management.
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