Delay in Medication Administration for Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for Resident R234, which adversely affected the resident's condition. The resident, who was admitted with diagnoses including Parkinson's disease, cardiac arrhythmias, bipolar disorder, and dysphagia, experienced pain and required medication. On the day of the incident, the resident's family requested pain medication, and the facility nurse discovered that only Tylenol was ordered as needed for pain relief. A new order for Norco was obtained from the Nurse Practitioner and sent to the pharmacy. Despite the new order, the facility nurse was unable to obtain the medication from the emergency medication kit due to the pharmacist's refusal to provide an authorization code. The pharmacist cited that the medication was already packed for delivery and could not be unpacked. This resulted in a delay of several hours before the resident received the first dose of Hydrocodone-Acetaminophen, which was administered late in the evening. Interviews with the resident and the Nursing Home Administrator confirmed the delay in medication administration. The resident expressed discomfort due to the delay, and the NHA acknowledged that the medication was available in the emergency stock and should have been administered earlier. The pharmacist's failure to communicate effectively with the physician for a one-time dose script contributed to the delay, impeding timely pain management for the resident.
Plan Of Correction
R234 received medication from the pharmacy that evening. Residents with medications that require a script were reviewed to ensure medication was on hand by the Director of Nursing/designee. Licensed staff were educated on the use of the emergency medication kit and the process to obtain authorization to pull a controlled substance, as well as who to contact if having difficulty, by the Director of Nursing/Designee. An audit will be conducted on new admissions and 8 other residents 3 times a week for 4 weeks to ensure controlled substances are provided timely by the pharmacy or a pull code was obtained timely by the director of nursing/designee, then weekly for 4 weeks, then monthly ongoing. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.