Morning Star Post Acute

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

inflammation), anxiety disorder(differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), irritable bowel syndrome (a common condition characterized by abdominal discomfort associated with altered bowel movements), and pain. During a review of Resident 5's MAR dated July 2025, the MAR indicated 7/19/25 Brimonidine Tartrate Ophthalmic Solution 0.2% (medication used to lower eye pressure by reducing fluid production in the eye) instill 1 drop in both eyes two times a day for eye lubricant at 18:00 [6 p.m.].Latanoprost Solution 0.0005% (medication used to lower eye pressure by increasing fluid outflow from the eye) instill 1 drop in both eyes at bedtime for eye lubricant at 20:00 [8 p.m.]. were held. During a review of Resident 5's Progress Note dated 7/19/25 indicated Brimonidine Tartrate Ophthalmic Solution and Latanoprost Solution 0.005% were pending delivery. During

an interview on 8/7/25 at 2:37 p.m. with the Registered Nurse (RN), the RN stated when medications were not available, the LN would call the pharmacy to find out when the medications would be delivered. The RN stated if medications were not given, the LN would document in the MAR and progress note. The RN stated if medications ordered were new and the facility was awaiting pharmacy to deliver the medications; the LN did not need to notify the physician. During an interview on 8/14/25 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the LN should have notified the physician when medications are unavailable and not given. The DON stated the nurse should have called the physician to report the medications were not available so the physician could decide if an alternative medication was needed. The DON stated the LN placed the residents at risk for worsening chronic health conditions by not reporting to the physician the medications were not given. The DON stated notifying the physician of medications not available and not given was standard practice. During a review of the facility's policy and procedure (P&P) titled, 7.0 Medication Shortages/Unavailable Medications, dated 8/01/24, the P&P indicated 5. If the medication is unavailable from Pharmacy or third-party Pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. 6. If the medication is unavailable from

the Pharmacy.Facility should collaborate with Pharmacy and Physician/Prescriber to determine a suitable therapeutic alternative. 7. If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for alternate orders/directions, making sure to explain the circumstances of the medication shortage.9. When a missed does is unavoidable, Facility nurse should document the missed dose, and the explanation for such missed dose, on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and the nurse's notes per Facility policy.During a review of the National Library of Medicine Professional Referenced titled, Nursing Rights of Medication Administration, published 4/4/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK560654/) the reference indicated, .Right time-administering medications at a time that was intended by the prescriber.A guiding principle of this ‘right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability of other chemical mechanisms.

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