Failure to Timely Reorder and Receive Breathing Medication
Penalty
Summary
The facility failed to ensure the timely reordering and receipt of a routine breathing medication for a resident, leading to the medication being unavailable at the prescribed time. During an observation, a Licensed Practical Nurse (LPN) confirmed that the inhaler for the resident was not in stock. The LPN stated that the inhaler had been reordered, but records showed discrepancies in the reorder and delivery dates. The Medication Administration Record (MAR) confirmed the inhaler had not been administered, and a progress note indicated that the physician was contacted to order the medication once it was received. The resident, who had been admitted and re-admitted with certain diagnoses, expressed that the medication occasionally ran out. The Care Plan for the resident included giving medications as ordered and monitoring side effects and effectiveness. During an interview, the Director of Nursing (DON) explained that inhalers should be reordered before they run out, depending on the type of inhaler. The facility's policy on medication ordering and receiving from the pharmacy emphasized timely receipt and accurate record-keeping, which was not adhered to in this instance.
Plan Of Correction
1. What corrective action will be accomplished? Resident #48 received ordered inhaler @ 5:59pm on. Resident #48 was assessed by ARNP and found to have no adverse effect related to delayed administration of inhaler. The licensed nurses caring for resident #48 were re-educated on the facility policy for re-ordering medication. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: An audit was conducted of current residents who have physicians order/receives inhalers to ensure all are stocked and re-ordered timely. 3. Measures/systematic changes put into place: The licensed nurses were re-educated by the DON/Designee on the facility policy for re-ordering medications (including inhalers). Re-ordering medication (including inhalers) was added to new nurse hire orientation and annual education. 4. How Corrective action will be monitored: The DON/Designee will conduct a daily audit (for 5 weeks) of residents with a physician order for inhalers to ensure the inhaler is available and re-ordered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.