Failure to Ensure Availability of Ordered Medications for a New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available for administration to a resident, as required under pharmaceutical services. The affected resident was an older adult admitted with multiple diagnoses including Parkinson’s disease, atrial fibrillation/flutter, chronic heart failure, type 2 diabetes, and hypertension, and had no cognitive impairment per a recent MDS, requiring assistance with ADLs. Review of the closed electronic clinical record and nurses’ notes showed repeated documentation that several ordered medications were not available for administration on multiple consecutive days (3/15/2025, 3/16/2025, and 3/17/2025). These medications included, but were not limited to, rivastigmine patch, amantadine ER, DDAVP nasal solution, clobetasol foam, amiodarone, ergocalciferol, and Rytary, all of which had valid physician orders. Nursing documentation repeatedly indicated that medications were “not available” or “awaiting pharmacy delivery” over several medication administration times, including bedtime and scheduled daily doses. Some medications listed as unavailable on 3/15/2025 and 3/16/2025 continued to be documented as unavailable on 3/17/2025. Interview with an LPN confirmed that medications should be available for administration and that nurses should try to obtain medications by the day after admission. The DON stated that medications were expected to be available as ordered, that the pharmacy had two scheduled daily deliveries, and that new admission medications should be available by the next day, but acknowledged that a rivastigmine patch documented as unavailable had in fact been delivered earlier that day per the pharmacy manifest. Review of the Pixus inventory showed none of the cited medications were available there. During the end-of-day debriefing, facility leadership acknowledged that medications should be available for administration as ordered.
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