Failure to Ensure Timely Prior Authorization Resulted in Missed Diabetes Medication Doses
Penalty
Summary
The facility failed to ensure a process was in place for timely prior authorization (PA) of medications, resulting in a resident missing multiple doses of a prescribed diabetes medication, Rybelsus. The resident, who was cognitively intact and had diagnoses including diabetes and heart disease, had a care plan directing staff to administer medications as ordered. However, medication administration records showed repeated missed doses of Rybelsus over several months, with gaps in March, April, and May. The missed doses were due to delays in completing and returning the required PA forms to the pharmacy, which prevented the pharmacy from dispensing the medication. Interviews with staff revealed a lack of clarity and knowledge regarding the PA process. The pharmacist confirmed that the facility did not return PA forms in a timely manner, and staff, including medication aides and nurses, were unsure of their roles in ordering and authorizing medications requiring PA. The medication aide reported notifying nurses about the need for refills but did not escalate the issue promptly when the medication did not arrive. Nurses and nurse managers were also unaware of the extent of missed doses, and documentation in progress notes did not consistently reflect the missing medication. The resident reported missing Rybelsus doses for about a month in March and April, as well as some in May, and stated that nurses attributed the delay to the need for administrative approval. The facility's medication orders policy did not include guidance on the PA process, contributing to the confusion and failure to ensure timely medication administration as ordered by the provider.