F0684

D

Failure to Ensure Availability and Administration of Ordered Medications

Riverton, Wyoming Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for a cognitively intact resident with paraplegia, cervicalgia, spina bifida, morbid obesity, and osteoporosis. The resident had physician orders for weekly oral alendronate sodium for osteoporosis and weekly subcutaneous tirzepatide (Zepbound) for morbid obesity. Review of the MARs over several months showed alendronate was repeatedly not administered and documented as “on order from pharmacy” on multiple scheduled administration dates in August, September, October, November, December, and January. In addition, there was a gap in tirzepatide orders and administration, with no evidence of an active order or administration for a period in December despite a prior start date and a later increased-dose order.

A physician consult documented that the resident had run out of tirzepatide and that no one had called for a refill, and also that the SNF had not picked up the alendronate, despite the physician’s review with nursing and the DON that these medications needed to be picked up and not allowed to run out. The physician further reported ongoing issues with medications not being available, the facility not notifying him, and the facility not picking up medications from the pharmacy, even though he had informed them that medications would be available for pickup within 24–48 hours after ordering and that they could obtain them from a local pharmacy if needed. These actions and inactions by facility staff led to multiple missed doses of ordered medications for the resident.