Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide physician-ordered medication for a resident, resulting in a deficiency. The resident was admitted to the facility with a hospital discharge medication list that included Pregabalin 75 mg to be administered three times a day. However, the resident did not receive the medication during five administration opportunities from admission until discharge. The medication administration record indicated that the medication was not available, and the pharmacy did not have the prescription. Interviews with staff revealed that the medication was not in the medication cart, and the pharmacy was contacted but did not have the prescription. The staff did not remember if the physician was contacted to obtain the prescription. The facility's emergency medication drug list showed that Pregabalin 25 mg was available, but the required 75 mg dose was not administered. The Director of Nursing confirmed that Pregabalin is a controlled medication requiring a prescription and that the medication was not delivered because the pharmacy did not receive a prescription. The facility's policy on administering medications states that medications should be administered safely, timely, and as prescribed. The Director of Nursing indicated that if a controlled medication is not available, the physician should be notified, and there should be documentation of this notification. Despite these procedures, the resident did not receive the prescribed Pregabalin, and there was a lack of documentation and follow-up to ensure the medication was provided.
Plan Of Correction
F 755 D- Pharmacy Services/Procedures/Pharmacist/Records Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on Identification of other residents having the potential to be affected: Current residents in the facility were reviewed by to ensure their medications requiring hard scripts were available in the medication cart. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed nurses by to ensure physicians are notified when a hard script is needed for a new medication and will continue to follow up with physician and/or pharmacy until medication is received. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review new admissions to ensure hard scripts were received or sent to pharmacy to ensure medication is delivered and available to the resident 3 times a week for 2 weeks then 2 times a week for 2 weeks then weekly. The administrator will oversee audit completion and report findings in the monthly Risk Management/QA Committee meeting for 3 months or until substantial compliance is achieved.