Failure to Follow Up on Ordered Medication and Ensure Administration
Penalty
Summary
The deficiency involved the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice when nursing staff did not follow up on a prescribed medication for one resident. The resident was admitted with diagnoses including benign prostatic hyperplasia (BPH), type II diabetes mellitus, and a wedge compression fracture of the first lumbar vertebra. A physician’s order dated 11/11/25 directed that the resident receive Finasteride 5 mg by mouth once daily for BPH. Review of the Medication Administration Record showed that Finasteride was not administered on 11/12/25 and 11/13/25. The EMAR administration note dated 11/13/25 documented that the Finasteride 5 mg tablet was “awaiting supply.” During interview and concurrent record review, the DON confirmed that the Finasteride doses were not given and that there was no shortage or inadequate supply of the medication. The DON stated that nursing staff had documented the medication as being on order and acknowledged there was no documentation that staff followed up with the pharmacy. Review of the facility’s “Medication Shortages/Unavailable Medications” policy indicated that nurses should call the pharmacy to determine order status, obtain medication from the emergency supply if delivery delays would cause a missed dose, arrange for emergency delivery if not available in the emergency supply, and document any unavoidable missed dose and explanation on the MAR/TAR and in nurse’s notes. These required follow-up and documentation steps were not carried out or documented by nursing staff for this resident’s Finasteride doses.
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