Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident, as evidenced by inconsistent administration and delayed reordering of prescribed topical medications. Specifically, an order for A&D ointment to be applied every shift for skin protection was not consistently fulfilled. Documentation in the Medication Administration Record (MAR) showed multiple instances where the ointment was not administered, with progress notes indicating it was on order, awaiting delivery, or being reordered. Staff interviews confirmed that the ointment was sometimes unavailable due to delays in reordering and supply, and that the process of obtaining the medication could take time, especially when only small tubes were available and frequent use was required. Additionally, a prescribed topical analgesic (Biofreeze) for knee pain was not available for several days after being ordered, and there was a lack of timely physician notification regarding its unavailability. The order for the analgesic was eventually changed after six days, but during that period, nursing notes repeatedly documented that the medication was on order or awaiting delivery. Interviews with nursing leadership acknowledged that staff did not act quickly enough to reorder medications or notify providers about the delays, resulting in the resident not receiving prescribed treatments as ordered.