F0755

D

Failure to Provide Ordered Medications Due to Pharmacy Unavailability

Shillington, Pennsylvania Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in pharmaceutical services when a resident’s physician-ordered medications were not available from the pharmacy and therefore were not administered as prescribed. The resident had been admitted with diagnoses including adrenocortical insufficiency and peripheral vascular disease, and the care plan included interventions for staff to administer medications as ordered by the physician. On January 17, 2026, the physician ordered hydrocortisone every eight hours and oxycodone every six hours as needed. Documentation showed that hydrocortisone doses scheduled for 6:00 a.m. and 2:00 p.m. were not given because the medication was unavailable from the pharmacy, and at 1:32 p.m. the nurse documented that oxycodone could not be administered for the same reason. In an interview, the Director of Nursing confirmed that these medications were not administered as ordered because they were not available from the pharmacy.

The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee, 28 Pa. Code 201.18(1)(3) Management, and 28 Pa. Code 211.12(d)(3)(5) Nursing services, based on the failure to ensure that ordered medications were available and administered to meet the resident’s needs.