Failure to Ensure Resident Free from Significant Medication Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as required by policy and physician orders. The resident, who had a history of chronic obstructive pulmonary disease (COPD), pulmonary embolism, and asthma, experienced multiple missed doses of critical medications, including a blood thinner (rivaroxaban), inhalers (umeclidinium bromide), roflumilast, and Dupixent injections. Documentation in the electronic medical record (EMR) and medication administration records (MARs) showed repeated instances where these medications were not available or not administered as ordered, with nursing staff noting the unavailability and pending pharmacy deliveries over several days. Interviews with staff and pharmacy personnel revealed that medication reordering processes were inconsistent, with reliance on fax or phone requests and a contingency supply (Pyxis) that did not contain the needed medications. The pharmacy indicated that some medications were sent according to insurance limitations, but there were lapses in communication and follow-through, resulting in missed doses. Nursing staff reported delays in medication delivery, even for STAT orders, and acknowledged that medications were sometimes not reordered in a timely manner or did not arrive as expected. The resident reported missing important medications for COPD and blood thinners, though he did not experience respiratory concerns or blood clots during the period in question. The physician and pharmacy both considered the missed doses of blood thinners and COPD medications to be significant medication errors. Facility leadership, including the DON and ADON, were not fully aware of the extent or frequency of the missed medications until after the fact, and expected staff to follow procedures for obtaining and administering critical medications.