Failure to Provide Timely Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that medications were readily available to newly admitted residents, resulting in delays in medication administration for two residents. One resident, who was cognitively intact and had multiple diagnoses including COPD, depression, and chronic respiratory failure, was admitted after the pharmacy's medication order cut-off time. The assigned LPN did not have access to the medication storage and was unaware of the process to obtain medications after hours or request a STAT delivery. As a result, the resident did not receive several scheduled medications on the evening of admission and the following morning, with documentation showing that medications were not delivered until the afternoon of the next day. Another cognitively intact resident with complex medical conditions such as diabetes, congestive heart failure, and stage 4 kidney disease also experienced delays in receiving medications. The resident's medication orders were not entered into the computer until the evening of the day after admission, and medications were not administered until the following day. The resident missed multiple doses of oral medications and insulin, and family members had to retrieve medications from the previous care setting due to the delay. There was no documentation that physicians were notified about the delays in medication administration. Facility policies required immediate action when medications were unavailable, including notifying the physician and obtaining alternative orders or emergency deliveries. However, staff did not follow these procedures, and there was a lack of communication and timely action to ensure that newly admitted residents received their prescribed medications as ordered.