Failure to Provide Timely Pharmaceutical Services Resulting in Missed and Late Medications
Penalty
Summary
The facility failed to provide timely pharmaceutical services for one resident, resulting in late and missed medication doses. The resident, who was admitted with diagnoses including aphasia following a stroke, right-sided hemiplegia, and gastrostomy status, required extensive assistance with activities of daily living but had intact cognition. Record reviews revealed multiple instances where medications were either documented as not given, left blank, or marked with a '9' on the medication administration record. Specific medications affected included atorvastatin, amantadine, famotidine, metoprolol, and heparin, with several doses either missed or not properly documented as administered. Interviews with the DON revealed that medication orders not submitted before a certain time would not be included in the next delivery, and the contracted pharmacy did not provide emergency drops for new admissions. The DON also stated that medications should be available in the backup supply, but was unable to provide a backup medication list when requested. Additionally, the DON indicated that the facility did not obtain medications from local pharmacies while waiting for deliveries from the contracted pharmacy. The pharmacy contract reviewed by surveyors required 24-hour emergency delivery for new or changed prescriptions, but this was not consistently followed, leading to the deficiency.