Failure to Provide Timely Access to Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were available and administered as ordered for two residents. For one resident with severe cognitive impairment and diagnoses including heart failure, diabetes, and depression, Modafinil was not available and therefore not administered on multiple dates following admission, despite a physician's order. The process for medication ordering involved the admitting nurse transcribing orders into the computer system, which were then sent to the pharmacy, with an expectation that medications would arrive within 24 hours. However, the medication was not available for several days, and alternative sources such as a local pharmacy or family-provided medications were not utilized in a timely manner. Another resident, who was cognitively intact and had diagnoses including hepatic encephalopathy and NASH, did not receive Xifaxan as ordered for several days due to the medication not being available. The medication was eventually obtained from the resident's previous assisted living facility, but not before multiple doses were missed. The facility's policy required staff to obtain medications from emergency supplies or arrange for STAT delivery if delays occurred, but these steps were not effectively implemented, resulting in missed doses for both residents.