Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, R56 and R61, who were prescribed Suboxone for opioid dependence. The facility's policy for Medication Shortage/Unavailable Medication requires urgent action by the licensed nurse in cooperation with the attending physician and pharmacy provider when medications are not received. However, this protocol was not effectively followed, leading to missed doses for both residents. Resident R56 missed multiple doses of Suboxone on November 27, 28, and 29, 2024, due to delays in medication delivery. Similarly, Resident R61 did not receive their prescribed doses on May 27 and 28, 2024, because the prescription was not filled and delivered in a timely manner. Interviews with the residents confirmed that there were times when the facility failed to provide their medication. The Director of Nursing acknowledged that the delays were due to the physician not sending prescriptions to the pharmacy promptly or the pharmacy not delivering the medication on time. This deficiency in pharmaceutical services is a violation of the facility's responsibility to ensure that residents receive their prescribed medications as needed.
Plan Of Correction
Resident R56 received their suboxone on 11/29/2024. Resident R61 received their suboxone on 5/28/2024. The facility completed a suboxone supply count immediately to verify appropriate supply before needing to request a refill. The facility has re-educated all licensed nurses on the facility's policy on Medication/Opioid Management and Reordering such as: when counting controlled drugs, the licensed nurses must be alert for medications needing refills or new script within 10 days of the last dose. The facility has re-educated on assessing and documenting residents for withdrawal symptoms and reaching the medical provider for an alternative to manage withdrawal symptoms and/or pain. The facility has informed the pharmacy account manager of the importance in receiving ordered medications in a timely manner and agreed upon filling the Omnicell/Pixus as a backup system. The facility will complete a medication audit on all residents who are presently on suboxone to monitor consistency and appropriateness of pain management regimen and receiving their medication in a timely manner. The facility will monitor and check for knowledge on licensed nurses' ability to verbalize understanding of facility's policy on Medication/Opioid Management and Reordering. The facility will monitor and check for knowledge on licensed nurses' ability to verbalize understanding of signs and symptoms of opioid withdrawal and how to appropriately assess and communicate with the medical provider for recommendations. The DNS will oversee and serve as the point of escalation in contacting the physician and/or pharmacy for refill and/or new script and specifically monitor Suboxone supply. The facility will monitor for timely receipt of medications from the pharmacy and immediately inform the pharmacy account manager of any concerns, as needed. DNS / designee will audit 4 residents prescribed Opioids to monitor consistent, timely and appropriate medication administration and pain management regimen. Audits will be conducted daily x2 weeks, then weekly x2 weeks and then monthly x2 months. Findings will be reported to the QAPI committee.