Failure to Provide Admission Medications Due to Gaps in Acquisition and Documentation
Penalty
Summary
The facility failed to ensure that routine, physician-ordered medications were acquired and provided upon admission for two residents. For one resident with multiple diagnoses including a right femur fracture, chronic pain, asthma, fibromyalgia, and migraines, there was no documentation of medication reconciliation or communication with the physician at admission. Progress notes indicated that several ordered medications, including Lyrica, Eletriptan, Venlafaxine, and Senokot S, were not available or administered for up to three days after admission. The medication administration record confirmed these medications were not given, and staff documented that medications were pending pharmacy delivery or not available, with some offers of alternative pain relief being refused by the resident. Another resident, admitted with diagnoses such as spondylosis, type 2 diabetes with nephropathy, muscle spasm, bacteremia, and repeated falls, also did not receive ordered medications upon admission. The resident reported not receiving any medications, including those for diabetes, during the first night, which was corroborated by the medication administration record and progress notes. The facility's emergency drug kit (EDK) contained metformin and other relevant medications, but there was no documentation that these were accessed or administered. Staff interviews revealed inconsistent processes for obtaining and administering medications from the EDK and pharmacy, with some staff indicating that medications could be delayed depending on delivery schedules and lack of clear documentation or communication with physicians regarding alternatives. Further interviews with facility leadership, including the DON and NHA, confirmed gaps in the medication acquisition process, lack of documentation regarding medication availability, and absence of policies related to obtaining medications from pharmacy services or the EDK. The DON acknowledged that medications such as metformin and rosuvastatin were available in the EDK but could not confirm why they were not administered. The NHA stated there were no policies guiding the acquisition of medications or use of the EDK, contributing to the failure to provide necessary medications to residents upon admission.