Failure to Administer Ordered Medications and Notify Prescriber When Drugs Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed medications as ordered and to notify the prescriber when medications were unavailable for one resident out of three sampled, in violation of the facility’s own policy on unavailable medications. The facility’s policy required staff to determine the reason and duration of medication unavailability, document efforts to obtain the medications, notify the physician when medications were not available, obtain alternative treatment or monitoring orders, and treat missed doses as medication errors with appropriate notifications and monitoring. These required actions were not carried out as specified in the policy. The affected resident had multiple significant diagnoses, including atrial fibrillation, atherosclerotic heart disease, hypertension, venous thrombosis and embolism, pulmonary embolism, pulmonary hypertension, osteoarthritis, anemia, orthostatic hypotension, myocardial infarction, benign prostatic hyperplasia, GERD, sciatica, neuropathy, congestive heart failure, postural orthostatic tachycardia syndrome, chronic respiratory failure, cellulitis of the left lower leg, and unstable angina. Physician orders dated in February 2026 included Eliquis, Midodrine, protein supplement, Methocarbamol, Finasteride, Lasix, Hydrocodone-Acetaminophen, Protonix, and Gabapentin. The Medication Administration Record for that month showed multiple missed doses: Eliquis, Gabapentin, Hydrocodone-Acetaminophen, Lasix, Protonix, and Midodrine each had missed administrations, and Methocarbamol and the protein supplement had multiple missed opportunities. Progress notes documented that upon the resident’s admission and over the following days, numerous ordered medications, including Eliquis, Midodrine, Methocarbamol, Finasteride, protein supplement, Hydrocodone-Acetaminophen, Lasix, Gabapentin, and Protonix, were repeatedly noted as “on order,” indicating they were not available for administration at the scheduled times. There is no documentation in the report that staff followed the facility’s policy to notify the physician or family, obtain alternative orders, or complete medication error reports for these missed doses. In interviews, the DON, Administrator, and Family Nurse Practitioner each stated they would have expected nursing staff to notify the pharmacy and prescriber when medications were not available and to follow the facility’s policy, confirming that these expectations were not met in this case.
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