F0755

E

Failure to Ensure Availability of Ordered Medications

Yukon, Oklahoma Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for one resident. Facility policy dated 01/2024 required medications to be administered as prescribed in accordance with manufacturers’ specifications and good nursing practices. Physician orders for the resident included divalproex 125 mg by mouth every 12 hours for unspecified dementia and levothyroxine 150 mcg by mouth in the early morning for hypothyroidism. Review of the resident’s February 2026 MAR showed multiple instances where levothyroxine doses were held due to unavailability on 02/07, 02/08, 02/14, 02/15, and 02/16 at 6:00 a.m., and one instance on 02/12 at 6:00 a.m. with no documentation. The MAR also showed divalproex doses held on 02/15 and 02/16 at 9:00 a.m. due to unavailability.

During interviews, CMA #2 stated the process to ensure medications were available was to order medications daily, typically when the supply was down to five days or less, and to call the pharmacy and notify the nurse if a medication was not in the building. CMA #2 also stated that when a medication was not available, they left the medication up on the MAR and notified the nurse, pharmacy, and then the DON. The DON and regional consultant stated medications should be ordered when down to a seven-day supply and, if not available, the physician and DON should be notified and the medication ordered STAT from the pharmacy. CMA #1 confirmed that an “H” on the MAR indicated a hold and verified that the resident’s levothyroxine and divalproex doses on the specified February dates were held because the medications were unavailable and needed to be ordered STAT, indicating the medications were not in the building at those times.