F0760

E

Repeated Unavailability of Specialty Medication Leads to Missed Doses

Rio Rancho, New Mexico Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Eltrombopag Olamine 50 mg PO daily for chronic thrombocytopenia was not administered on multiple occasions due to the medication not being available in the facility. The resident, admitted with a femur fracture and diagnosed with low platelets, had physician orders specifying daily administration of Eltrombopag Olamine and instructions to reorder when only 10 tablets remained. Review of the MAR showed the medication was not administered on multiple date ranges, and nursing progress notes repeatedly documented that the medication was either not in stock, not available in the facility, or that staff were waiting on delivery from the pharmacy.

During interviews, the resident reported not receiving the Eltrombopag Olamine for several days and stated this had happened multiple times before. The UM confirmed the resident had missed several doses because the medication had not yet arrived and acknowledged this was not the first time the medication was unavailable. The RN stated it was her expectation that all residents receive medications as ordered and noted that missing this medication could affect platelet function in the event of bleeding. The Medical Director reported being aware of issues with the resident not receiving the medication as ordered, explained that the drug was obtained through a specialty pharmacy with refill delays of a week or more, and attributed the problem to inconsistent ordering practices by different staff, with no single person consistently ensuring timely delivery. The facility’s own Medication Administration Policy required medications to be administered according to prescriber orders and appropriate interventions for medication errors, which did not occur in this case.