Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of several residents, resulting in multiple missed medication doses. For one resident with type II diabetes and central pain syndrome, Basaglar insulin was not administered due to the insulin pen being unavailable, and Gabapentin was missed over two days because the medication was out of stock and not delivered by the pharmacy in time. Another resident receiving hospice care and diagnosed with dementia did not receive Lorazepam for anxiety over several scheduled doses because the medication was not accessible following a pharmacy change and a delay in staff training on the new medication unit. A resident with congestive heart failure did not receive a scheduled dose of Torsemide as the medication was not available and was awaiting delivery from the pharmacy. Additionally, a resident with congestive heart failure and hypothyroidism missed two doses of levothyroxine because the medication was not available and was still pending arrival from the pharmacy. In each case, the Nursing Home Administrator confirmed that the medications were not administered as ordered due to unavailability or delays in pharmacy delivery.