Failure to Administer Ordered Platelet-Stimulating Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a prescribed medication as ordered by the physician. Resident #124 was admitted with thrombocytopenia and had a physician’s order dated 11/14/25 for eltrombopag olamine 50 mg by mouth at bedtime. The November 2025 MAR showed the medication was not administered on 11/14/25, and a nurse note for that date documented that the pharmacy would not dispense the medication. An incident report later indicated the medication had actually been received on 11/14/25 and was locked in the narcotic box on the medication cart, yet the resident did not receive the medication on 11/14 and 11/15. A nurse note dated 11/15/25 stated they were waiting on delivery, and the November MAR also showed the medication was not administered on 11/15/25. Staff statements further described the actions and inactions that led to the missed doses. CMA #1 stated there was a medication for Resident #124 that they could not find and that they must have overlooked it; they reported looking everywhere for it, being unable to find it, and then marking it as not in the building when the resident’s family member wanted the medications immediately. CMA #1 acknowledged they should have called the ADON. An email from CMA #2 to the ADON stated they did not recall if the medication was given. A facility document showed CMA #2 was terminated in part for not administering the medication on 11/14/25. The ADON stated that when a medication cannot be found, medication aides are to notify the nurse and the nurse is to notify the physician, and also stated they had counted the resident’s medication with CMA #2 and did not know why it was not given on 11/15/25.
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