Failure to Ensure Timely Availability and Administration of Critical Medications
Penalty
Summary
The facility failed to ensure the availability and timely administration of prescribed medications for four residents with significant mental health diagnoses. For one resident with paranoid schizophrenia, bipolar disorder, and major depressive disorder, there were missed doses of Venlafaxine and Clonazepam due to medication unavailability. Nursing notes and interviews confirmed that these medications were not available at the time they were due, and the pharmacy required blood work prior to dispensing, which was not always provided in a timely manner. Another resident with schizoaffective disorder, bipolar disorder, and major depressive disorder did not receive multiple doses of Clozapine because the medication was not available, as documented in nursing progress notes. The pharmacy required current lab results before dispensing Clozapine, and it was the responsibility of nursing staff to ensure these were sent. The DON confirmed the missed doses and indicated that staff were expected to notify him and the provider about such issues, but this did not occur. A third resident with schizophrenia missed several scheduled doses of Haloperidol Decanoate injections over multiple months. Documentation showed that the medication was not available on the scheduled dates, and there was no evidence the doses were administered after the medication arrived. Nursing staff reported difficulties with timely pharmacy deliveries and acknowledged that missed doses could lead to behavioral regression. A fourth resident with paranoid personality disorder and schizoaffective disorder missed nine consecutive doses of Clozapine and three doses of Austedo due to nursing staff not relaying required lab results to the pharmacy, resulting in a hospitalization. Facility policies required medications to be reordered at least three days before running out, but this was not consistently followed.