Delayed Medication and Vaccine Administration Due to Pharmacy Errors
Penalty
Summary
The pharmacy failed to ensure timely availability of medications for multiple residents, resulting in missed or delayed administration of prescribed drugs and vaccines. One resident with type 2 diabetes and chronic kidney disease did not receive their scheduled Ozempic injection because the medication was not available at the time of administration. The registered nurse confirmed that the medication should have been reordered and available, but a pharmacy error led to the delay. Another resident, admitted with obesity, diabetes, heart disease, and overactive bladder, consented to receive the Prevnar 20 pneumococcal vaccine. Despite multiple orders and documentation attempts, the vaccine was not received from the pharmacy and was not administered as scheduled. The directors of nursing were unaware of the reason for the delay and had to follow up with the pharmacy, which repeatedly failed to deliver the vaccine as expected. A third resident, admitted with a urinary tract infection and other conditions, was prescribed Cefpodoxime, an antibiotic, to be administered twice daily for three days. The medication was not available in the facility's contingency box, and the pharmacy did not deliver it until several days after the initial order. As a result, the resident missed multiple doses, and there was no documented evidence that the physician was notified of the missed doses on two of the days.
Plan Of Correction
The facility will continue to ensure medications are available timely for administration. Resident #64 continues to reside at the facility and received his Ozempic on 3/26/2025. Resident #236 continues to reside at the facility and has completed her round of ATB for UTI without negative effects. Resident #238 continues to reside at the facility and received her Prevar 20 vaccine on 3/27/2025. Resident #236 was assessed by facility nurse on 4/10/2025 and was noted to be free of s/s of UTI. An initial audit of all medications to ensure timely availability for administration was conducted by DON 4/10/2025. No negative findings were noted. The DON and Administrator reviewed survey findings with facility pharmacist on 4/18/2025. The Administrator, DON and IDT reviewed facility processes for pharmacy orders and deliveries on 4/17/2025. Infection preventionist will monitor deliveries and administration of vaccinations and antibiotics ensuring they are provided timely. Admission orders will be reviewed in clinical meetings ensuring medications are available and given timely. By 4/17/2025, the DON and or designee will reeducate licensed nurses on proper transcription of pharmacy orders, ensuring timely administration, and notifying PCP when medications are not available to be given. Weekly for 2 weeks, or as directed by the QA committee, the DON or designee will audit medication orders ensuring proper transcription of orders and that they were administered timely and as prescribed. Negative findings will be corrected by notifying practitioner and reeducating staff. Negative findings will be reported to the QA committee for review. The Administrator will ensure completion of the weekly audits. The DON is responsible for the ongoing compliance.