Failure to Provide Prescribed Medications Due to Unavailable Pharmacy Stock
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services were available so that physician-prescribed routine medications were administered as ordered for two residents. For one resident with diagnoses including heart failure, kidney failure, type II diabetes, anemia, SIRS, and acute upper respiratory infection, the MAR for February 2026 showed multiple missed doses of ordered medications because they were unavailable at the facility. These included artificial tears not given for an evening and night time period, ferrous sulfate not given on one day, sliding-scale insulin lispro not given before breakfast on one day, ipratropium-albuterol nebulizer solution not given for a scheduled morning dose, and methylprednisolone not given for a morning time block. The resident reported that staff had informed her on more than one occasion that they were out of her routine medications. A second resident, with diagnoses including type II diabetes, heart failure, and kidney failure, also did not receive prescribed medications due to unavailability. Record review showed that this resident’s daily cyanocobalamin (vitamin B-12) was not administered on one day in January 2026 because it was unavailable, and a scheduled evening dose of Novolog insulin was not given on another day for the same reason. The facility’s written policy stated that the facility would have sufficient personnel and a medication distribution system to ensure safe administration of medications and that medications are administered in accordance with written prescriber orders, but the documented missed doses due to unavailability demonstrate that this did not occur for these two residents.
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