Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure the timely availability of medications for three residents, resulting in missed doses. Resident R1, diagnosed with epilepsy, cerebral palsy, and major depressive disorder, had a physician's order for Lacosamide, an anticonvulsant medication, which was not administered as ordered on four occasions due to delays in pharmacy delivery. Similarly, Resident R2, with diagnoses including pneumonia and chronic obstructive pulmonary disease, missed four doses of Cefazolin Sodium Injection Solution, an antibiotic, because the facility was waiting for the pharmacy to deliver the medication. Resident R3, who had an infection of an amputation stump and a malignant neoplasm, was prescribed Piperacillin Sodium Tazobactam Sodium Solution, another antibiotic, but missed six doses due to the same issue of delayed pharmacy delivery. The Director of Nursing confirmed that the medications for these residents were not provided in a timely manner, leading to the missed doses. The facility's policy on medication delivery was not adhered to, as emergency deliveries were not utilized to ensure timely administration of medications.
Plan Of Correction
Intervention with regard to R1, R2 and R3: We have reviewed the case files of these residents and have determined that there were no adverse effects experienced due to the events cited. Interventions for all residents: 1. All residents' medications were reviewed by the pharmacist to ensure medications were present in the facility and made an urgent request to pharmacy in the event that medications that were not available. 2. New Admissions will be reviewed by Director of Nursing (DON) or designee to ensure medications were delivered as per order on next business day. 3. Review of the in-house medication storage and distribution vault (aka Cubex) was completed on January 15, 2025 and medication Cefazolin was added to the Cubex. 4. All licensed staff will be educated by the DON or designee on admission process for new medications to include medication in Cubex, calling pharmacy for late admissions, printing orders and faxing to pharmacy for controlled substances. They will also be trained on the medication re-ordering process in order to mitigate lapsed medication orders. Monitoring of the change to sustain system compliance ongoing: The DON/designee will monitor medication orders 5 times a week for 4 weeks to ensure medications are available to administer then monthly for 2 months and ongoing. Findings will be reported to Quality Assurance and Performance Improvement (QAPI) committee for review and recommendations.