Failure to Administer Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to administer physician-ordered medications as prescribed for four residents, resulting in multiple missed doses of critical medications. For one resident with diagnoses including end-stage renal disease, COPD, and diabetic neuropathy, there were several days where a prescribed pain medication (Pregabalin) was not administered due to delays in obtaining a new prescription and pharmacy refill. Documentation showed that both nursing staff and the pharmacy attempted to contact the physician for a new script, but the medication was not available for several days, during which the resident reported experiencing pain. Another resident with a history of diabetes, obesity, and neuropathy also experienced repeated interruptions in receiving Pregabalin, with missed doses documented and the resident reporting frequent shortages of the medication. The DON acknowledged ongoing issues with the medication ordering system, particularly for controlled substances, and noted that the facility was transitioning to a new medical director and system, which contributed to the delays. Nursing staff were sometimes unaware of the missed doses, and the facility's policy required timely reordering of medications before supplies were exhausted, which was not consistently followed. Additional residents were affected by similar issues. One resident with Parkinson's disease missed several doses of Gocovri (amantadine), with progress notes indicating the medication was on order or awaiting delivery from the pharmacy. Another resident missed multiple doses of prescribed estrogen cream, with no documentation in the progress notes explaining the missed doses. Interviews with staff and family confirmed that medication administration was inconsistent due to delays in obtaining medications and communication issues between the facility, pharmacy, and prescribers.