Failure to Provide Timely Pharmaceutical Services Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in multiple instances where prescribed medications were not administered as ordered. The resident, who was cognitively intact and had diagnoses including pneumonia, COPD, pulmonary fibrosis, congestive heart failure, and chronic atrial fibrillation, reported not receiving all her medications and noted that some were given very late. Staff informed her that the medications were not administered because they had not been received from the pharmacy. A review of the Medication Administration Record (MAR) revealed that several medications, including alprazolam, calcium citrate with vitamin D, Effexor XR, gabapentin, magnesium oxide, and venlafaxine, were documented as not available and therefore not given on multiple occasions. The DON confirmed awareness of these missed doses due to unavailability. The facility's policy required adherence to the five rights of medication administration, but these were not met in this case.