Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for three of four residents reviewed for medication availability. Multiple instances were documented where residents did not receive their prescribed medications due to unavailability, delays in pharmacy delivery, or issues with reordering and insurance authorization. For example, one resident with chronic conditions such as COPD, heart failure, and depression missed several doses of critical medications including blood thinners, antidepressants, antibiotics, steroids, and inhalers. Documentation in the electronic medical record and medication administration records showed repeated notations of medications being unavailable, on order, or pending delivery, with some medications not being delivered for multiple days. The resident confirmed missing important medications and staff interviews revealed challenges with the pharmacy's delivery system, insurance limitations, and the facility's reordering process. Another resident with mood disorder and depression did not receive a prescribed antidepressant because it was not available at the time of administration. The LPN responsible for medication administration noted the medication was on order and not delivered, and the pharmacy confirmed that while the medication was filled, it was not yet sent out. The facility's contingency supply was supposed to cover such gaps, but staff reported that it did not contain many needed medications. The DON and ADON acknowledged ongoing issues with medication availability, difficulties with the pharmacy's ordering system, and the need for frequent follow-up with the pharmacy to track and obtain medications. A third resident with hypercholesterolemia experienced multiple missed doses of a cholesterol-lowering medication due to unavailability and delays in pharmacy delivery. The MAR and clinical documentation indicated several days where the medication was not administered because it was either unavailable or waiting on delivery. The pharmacy records showed that insurance limitations sometimes restricted the amount dispensed, resulting in the need for more frequent reorders. Staff interviews confirmed that the resident often ran out of medication and experienced delays, and the contingency supply did not include the needed medication. The DON provided evidence of some training on medication availability but acknowledged that documentation was not specific enough to address the delays experienced by this resident.