Failure to Provide Timely Pharmaceutical Services for Multiple Residents
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of three residents, resulting in multiple missed doses of critical medications. For one resident with a history of hypertension, the facility did not procure or administer a prescribed antihypertensive medication, Amlodipine Besylate-Valsartan, for several days. Documentation errors were noted, as the medication was marked as administered on days when it was not available in the facility. The Director of Nursing (DON) confirmed that the medication had never been delivered, and there was no system in place to confirm receipt of ordered medications or to document incidents of omitted medication. Staff interviews revealed ongoing issues with pharmacy delivery and communication, with repeated but ineffective attempts to resolve the problem. Another resident, who suffered from severe pain due to a foot ulcer, traumatic amputation, and urethral erosion, did not receive prescribed topical pain medications (Lidocaine Gel and Biofreeze) for the majority of scheduled doses. The medications were not available from the pharmacy, and there was a lack of clear communication and follow-up between nursing staff and the DON regarding the unavailability. The resident continued to experience pain during care, and staff acknowledged the absence of the medications but could not specify when the last request for them had been made. A third resident, with complex medical conditions including myasthenia gravis and undergoing chemotherapy, did not receive several essential medications, including an immunosuppressant, an antiviral, and an artificial saliva product, over an extended period. Medication administration records repeatedly documented these medications as "not available." The DON was unaware of the ongoing issue until it was brought to her attention during the survey, and there was no evidence of consistent follow-up with the prescribing provider or pharmacy. The lack of a reliable system for tracking and ensuring the delivery of ordered medications contributed to the ongoing deficiencies in pharmaceutical services for these residents.