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 of prescribed medications due to unavailability. The facility's Director of Nursing (DON) confirmed that the onsite pharmacy was closed on a holiday, and there was no documentation of follow-up with the pharmacy or physician notification regarding the unavailability of medications. Resident #5 also experienced missed medication doses due to the facility not having the correct medications. The DON revealed that the facility had Acidophilus instead of the prescribed Rhamnosus, leading to inconsistent administration by nurses. Additionally, the liquid form of a medication was unavailable, and some nurses used a pill form instead. There was no documentation from the pharmacy or nurses to clarify or obtain the correct medications in a timely manner. Resident #6 did not receive prescribed medications upon admission due to unavailability. Progress notes indicated communication with Omnicare and hospice, but the medications were not delivered promptly. The DON confirmed the absence of an emergency kit and that all medications were delivered by Omnicare, with no documentation of a STAT request for prompt delivery.
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.