Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. Resident #2 was admitted with several medication orders, but did not receive the evening doses on the day of admission and the following morning due to the unavailability of drugs. The facility's pharmacy was closed for a holiday, and although a request was faxed to Omnicare, there was no follow-up or documentation of physician notification. Resident #5 did not receive prescribed medications on multiple occasions due to unavailability. The facility had Acidophilus instead of the prescribed Rhamnosus, and some nurses administered a pill form of a medication instead of the prescribed liquid form. There was no documentation of efforts to clarify or obtain the correct medications. Resident #6 also experienced delays in receiving medications. Despite being a new admit and expressing concern about the unavailability of medications, the facility did not have an emergency kit and relied on Omnicare for delivery. Progress notes indicated communication with Omnicare and hospice, but there was no documentation of a STAT request for prompt delivery. The facility's failure to follow procedures for acquiring and administering medications in a timely manner led to these deficiencies.
Plan Of Correction
Resident #2 was not negatively affected by the findings. Resident #5 was discharged to home on 3.5.25. Resident #6 was discharged to hospice house on 2.10.25. All residents have the potential to be affected. On [date], an audit was conducted by the Director of Nursing of all resident medications administration records from 3.13.2025 to 3.25.25 for missed doses. Education was provided by Staff Development Coordinator/Designee to the nurses on the facility protocol regarding pharmaceutical services related to acquiring and administering medications in a timely manner. The DON/Designee will conduct a weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.