Failure to Administer Prescribed Medications Upon Readmission Due to Pharmacy Processing Error
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for one of five sampled residents following readmission. Upon review of the medical records, it was found that the resident had multiple physician orders for medications including omeprazole, venlafaxine, lamotrigine, lisinopril, metformin, metoprolol, vitamin C, acetaminophen, magnesium hydroxide, gabapentin, vitamin B-12, clonidine, and dextromethorphan-guaifenesin. Despite these orders, the resident did not receive the majority of these medications upon readmission, with only gabapentin being available initially. Interviews with nursing staff revealed that the medications were not delivered as expected, prompting the LVN to contact the pharmacy, refax the orders, and notify both the nursing supervisor and the physician. The medications remained unavailable for several days, and further attempts were made to communicate with the pharmacy and notify the DON. The delay in medication delivery persisted from the day after readmission until at least two days later, during which time the resident did not receive the prescribed treatments. A review with the Pharmacy Manager identified that the resident's readmission orders were electronically misfiled, resulting in the medications not being processed or delivered in a timely manner. The pharmacy's tracking log confirmed delays in receiving and processing the orders, with some medications not being sent until days after the initial request. Facility leadership, including the DON and Administrator, verified these findings during interviews.