F0755

E

Widespread Failure to Provide Ordered Medications Due to Stock, Ordering, and Coordination Breakdowns

Bellingham, Washington Survey Completed on 02-13-2026

Penalty

Fine: $15,935

Summary

The deficiency involves the facility’s failure to provide all physician‑ordered medications to residents on 13 of 14 reviewed days for 20 residents, disrupting continuity of care and placing residents at risk of not having their medical needs met. Review of the facility’s Medication Not Available report for 01/30/2026 through 02/12/2026 showed numerous prescribed medications, including anticonvulsants, respiratory medications, gastrointestinal medications, antidepressants, antiplatelet agents, thyroid medications, diabetic medications, cardiac medications, hormone therapies, pain medications, supplements, and OTC products, were not administered because they were not available. The report also documented that some medications were available in the facility’s pyxis machine or should have been available as OTC facility stock, yet were still not given.

The Medication Not Available report detailed repeated instances where residents’ medications were not administered despite prior deliveries or available stock. Examples included residents missing doses of gabapentin, albuterol inhalation, fluticasone‑salmeterol inhalers, metronidazole topical cream, ranitidine, duloxetine, levothyroxine, semaglutide, clopidogrel, diltiazem, oxybutynin, pantoprazole, estradiol, alendronate, and various vitamins, minerals, and protein supplements. In several cases, the pharmacy had delivered 7‑, 14‑, 28‑, or 30‑day supplies on earlier dates, but the medications were still documented as unavailable later, and refill requests were sometimes submitted after the expected depletion date. The consulting pharmacist later confirmed that many of the medications listed should have been on hand based on previous delivery dates and that some medications were available in pyxis at the time they were reported as not administered.

Staff interviews described systemic problems with obtaining both pharmacy‑dispensed and OTC medications, as well as confusion and breakdowns in responsibility for ensuring medication availability. Nursing staff, including RNs and LPNs, reported that OTC medications were often not available, that management discouraged documenting unavailable medications, and that they were directed to speak with the Administrator or HR, who in turn reported not having a card to purchase needed OTC items. Agency nurses reported they could not access the pyxis and had to rely on regular staff to obtain medications, and that notifications to Resident Care Managers did not always result in orders being placed. Nursing staff and managers described ongoing issues with pharmacy deliveries, including medications not arriving despite being ordered, delays related to ordering cut‑off times, and high‑cost medications requiring administrative approval and signatures. The contracted pharmacist stated they were unaware of delivery difficulties, noted a 5–7 day refill turnaround time, and identified late refill requests and missed admission doses where orders were submitted late in the day and no rush requests were made, contributing to the pattern of unavailable medications.

Additional interviews with leadership and clinical staff further illustrated the lack of clarity and follow‑through in the medication supply process. An interim CNO stated they did not know where the disconnect was in having medications available. A Resident Care Manager acknowledged continuous issues with the pharmacy and stated that medications listed on the Medication Not Available report were simply not available, whether pharmacy‑delivered or facility‑supplied OTCs, and that the problem had been ongoing. Nursing staff reported that when medications were not available for a day or two, they tried to notify providers, and that they often had to call the pharmacy multiple times, sometimes being told that medications had not been ordered even when staff believed they had been. The consulting pharmacist’s follow‑up email also noted that several medications on the report should have been available as OTC stock, that many should have been on hand based on prior deliveries, that refill requests were often delayed beyond the expected depletion date, and that for one admission, multiple ordered medications were available in pyxis but not used, and no rush request was submitted for the remaining medications, resulting in missing doses on the evening of arrival.