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Based on observation, interview and record review the facility failed to ensure that medications were dispensed to patients as ordered. Citing two (2) patients (ID#1, 3) out of ten (10) patients receiving medications at the facility.

Findings include:
Record review of the medication administration record revealed one patient (ID #3) did not receive:

Thyroid Armour 30 mg PO in the a.m. The medication was not available 10/7/2017-10/10/2017. No indication in the nurses notes that the nurse practitioner or physician were notified.

Klonopin 1 mg PO daily on 10/10/2017: Patient (ID#3) did not receive the medication, with no documentation by the nursing staff, why the dose was missing.

Record review dated10/26/2017 to 10/29/2017 of the medication administration record revealed patient (ID #1)
Flagyl 250 mg TID x 5 days- the nurses noted the medication was not available. There was no indication in the nurses noted if the physician or the NP was notified.

Record review dated 10/29/2017 at 6:20 p.m. revealed a telephone order from NP (ID# 59), order taken by RN (ID #62), for: Diflucan 150 mg PO x 1 dose now. Review of the medication administration record there was no indication the patient received the drug.

Record review dated 10/29/2017 at 9:00 p.m. by MD (ID#60), ordered: Benadryl 50 mg PO x1 now and prn (whenever necessary). Review of the medication administration record there was no indication the patient received the drug.

Interview on 10/31/2017 at 10:30 a.m. with staff nurse (ID #65), RN stated the nurses would notify the physician or NP to let them know the drug is not available and order for a substitution should be obtained. She also stated this was missed and a variance report should have been generated and this should not have happened.

Record review of current hospital policy "Incident Report Protocol, dated 3/2017 revealed; "It is the responsibility of all staff to report all "incidents" (any event not consistent with routine operations) accidents, injuries, unsafe conditions, occupational illness or property damage involving patients, personnel, or visitors, and to report such occurrences using an Incident Report form". Medicine variances are considered an incident.