Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure timely availability of medications for two residents, leading to missed doses. Resident CR1 had a physician's order for insulin glargine to manage diabetes, but the evening dose on January 3, 2025, was not administered because the medication was unavailable. The resident's blood sugar was recorded at a high level of 227 mg/dL, and there was no evidence that the physician was contacted or that an alternative was provided. The following morning, the resident's blood sugar had increased to 449 mg/dL, prompting the on-call physician to order a one-time dose of rapid-acting insulin, which successfully reduced the blood sugar level. Resident 2 had a physician's order for a lidocaine patch for pain management, but the patch was not administered on the morning of January 7, 2025, as it was still on order. The Director of Nursing confirmed the unavailability of the patch. These incidents indicate a failure in the facility's pharmacy services to provide necessary medications in a timely manner, as required by the residents' care plans.
Plan Of Correction
1. Corrective action cannot be achieved for resident CR1. Resident 2 was provided ordered medication and provider was notified of missed dose with no orders to change plan of care. Pain assessment was completed and reflected no increase in pain as a result of missed dose. 2. All residents have the potential to be affected. Facility will monitor MAR/TAR for medication designated as "not administered" for the reason of not available and either obtain medication through alternate pharmacy, OTC vendor, or notify provider for alternate medication and/or directive. An inventory of over-the-counter medications to be obtained and compared to facility need. Supplies to be ordered to meet facility need. Additional medications to include frequently used insulins were ordered for emergency backup usage. 3. Education will be provided to medical providers and nursing staff using a program developed by a well-established center of geriatric health service education, and will include a review of all the federal regulations cited along with a review of the accompanying guidelines for F-0755, and any changes to facility policies and procedures. 4. DON or designee will monitor MAR/TAR for documentation of meds not available for 10 residents weekly x 4 weeks then monthly x 3 months. Results of audit will be reviewed with QAPI process and meetings.