Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services in two separate incidents involving two residents. In the first case, a resident who had recently undergone a dental extraction was prescribed Chlorhexidine Gluconate Oral Rinse for post-extraction care. Despite a physician's order dated the day after hospital discharge, the medication was not available or administered for five consecutive days. The nurse confirmed the medication was unavailable since the order date, and the medication administration record showed no doses given during this period. The medical director stated that the order had been sent to the pharmacy, but there was no communication from the pharmacy regarding the delay or non-delivery. In the second incident, a resident with diabetes was prescribed insulin lispro to be administered per a sliding scale. During medication administration, the nurse administered insulin aspart instead, as insulin lispro was not available. The electronic medication administration record incorrectly documented the administration of insulin lispro, and the nurse explained that the pharmacy had linked both an insulin aspart sliding scale order and an inappropriate fixed-dose lispro order under the original lispro order. The consultant pharmacist confirmed that insulin aspart and insulin lispro are different medications and that a new physician order is required to substitute one for the other. The assistant director of nursing acknowledged that the pharmacy's action to auto-link these orders was inappropriate and not based on the resident's actual orders. A review of facility policy indicated that the provider pharmacy is responsible for accurately dispensing prescriptions based on authorized prescriber orders and ensuring timely delivery of medications. The pharmacy is also required to screen new medication orders for appropriate indications and communicate with nursing staff if additional information is needed before administration. In both incidents, the pharmacy failed to meet these requirements, resulting in missed and incorrect medication administration.