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Based on medical record review, review of policy and procedures, and staff interview it was determined the facility failed to ensure the patient was administered medication per the orders of the physician and accepted standards of practice for one (#6) of twelve patients sampled.

Findings included:

Review of the medical record for patient #6 revealed the patient was admitted to the facility on 11/8/2022. Review of the physician's orders, dated 11/9/2022, no time documented, revealed an order for Amantadine 100 mg (milligrams) daily. Review of the MAR (Medication Administration Record) revealed on 11/9/2022 at 9:00 AM the record was blank with no documented evidence the medication was administered. Review of the MAR, dated 11/10/2022 at 9:00 AM the nurse documented the medication was "unavailable" and was not administered. Review of the MAR, dated 11/11/2022 at 9:00 AM the nurse documented the medication was "not available" and was not administered.

Review of the physician's orders, dated 11/9/2022, at 7:10 PM, revealed an order for Fluvoxamine 100 mg by mouth QAM (every morning) and 300 mg by mouth QHS (every hour of sleep). Review of the MAR (Medication Administration Record) revealed on 11/9/2022 at 9:00 PM the nurse documented "can't override" and the medication was not administered.

On 12/7/2022 at 9:45 am an interview was conducted with the CNO (Chief Nursing Officer). The above findings were reviewed with the CNO. She stated when the nurse finds a medication is not available in the patient's medication profile or if the medication is not available for override the nurse should immediately notify the pharmacy to address the issue. The CNO reviewed the record and confirmed the findings and no evidence the pharmacy was notified to address the medication availability. The CNO confirmed there was no evidence the physician was notified the medications were not administered.

Review of the facility policy #NS-100, "Medication Administration," revealed on page 6 of 6, "...if for any reason any scheduled drug is not administered...document physician notification in the Progress Note."