Failure to Provide Timely Pharmaceutical Services for Pain Management
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident admitted with a right ankle fracture and oral thrush, who had an order for Magic Mouthwash to be administered four times daily for throat pain. According to the medication administration record, the mouthwash was not available from 4/10/25 to 4/23/25, and the resident did not recall receiving it during this period. An agency LPN reported contacting both the pharmacy and the provider on two occasions to notify them that the medication was unavailable. The facility pharmacist stated that the pharmacy had reached out to the facility on 4/14/25 to clarify the medication ratios needed to compound the mouthwash but did not receive a response, resulting in the medication not being delivered until 4/25/25. The Director of Nursing acknowledged that the resident did not receive the ordered medication as prescribed.