Inadequate Pharmaceutical Services Lead to Medication Delays
Penalty
Summary
The facility failed to implement adequate pharmaceutical services, resulting in the inaccurate provision of medications for two residents. For Resident R51, the issue was identified when a registered nurse was unable to locate the prescribed Zoloft medication in the Pyxis machine, which was supposed to contain four tablets but only had one. The nurse had to seek assistance to access the machine, and upon further investigation, it was found that the pharmacy had not been notified of the discrepancy, leading to a delay in medication delivery. Resident R128 experienced multiple instances of unavailable medications, including Dorzolamide HCl-Timolol Mal Ophthalmic Solution, Selegeline Transdermal Patch, and Clonidine HCl Oral Tablet, among others. These medications were not administered as ordered due to delays in delivery from the pharmacy. The progress notes indicated repeated instances of medications being on order or awaiting arrival, yet there was no documentation of follow-up actions to ensure timely delivery. Interviews with facility staff, including the Nursing Home Administrator, Director of Nursing, and Pharmacy Director, revealed a lack of effective communication and coordination with the pharmacy. The facility did not have a backup pharmacy plan, and there were inconsistencies in the restocking and monitoring of the Pyxis machine. The pharmacy director confirmed that the facility had not communicated the need for medication refills, contributing to the ongoing issue of unavailable medications for the residents.
Plan Of Correction
1. The facility is unable to go back and make certain physician orders were followed and a resident received treatment and care in accordance with professional standards of practice. Residents R51 and R128 had no adverse reactions. 2. DON completed whole house investigation on missing medication. MD was notified of any missed medication and discussed new orders received when medication is unavailable. Staff interviewed on medication re-ordering. Licensed staff educated on medication re-ordering. 3. DON/designee will complete a 30-day lookback of all current resident's medication list, and audit carts for medication availability. 4. DON/designee to educate licensed staff on emergency medication supply, access to emergency medication supply, physician notification requirements of meds not available, and documentation requirements. 5. DON/designee to audit RX NOW machine 1x/week for 3 weeks, then 1x/month for 3 months. 6. DON to audit cart medication availability 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 7. Results to be submitted to QAPI for review and approval.