Failure to Provide Ordered Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to ensure that medication was obtained and provided as ordered by the physician for one resident. Specifically, a review of the clinical record for a resident with diagnoses including diabetes, hypertension, and gastroesophageal reflux disease showed a physician's order for caladryl external lotion to be applied topically to a rash twice daily for seven days. However, the treatment record for the relevant months did not contain evidence that the caladryl lotion was applied as ordered. Nursing documentation indicated that the facility was waiting for delivery of the caladryl lotion from the pharmacy, and there was no documentation that the medication was received or administered. The Director of Nursing confirmed that there was no evidence of receipt or application of the medication per the physician's order. Facility policies required medications to be administered according to prescriber orders and for the prescriber to be contacted if medication delivery would be delayed, but there was no documentation that these procedures were followed.
Plan Of Correction
1) Medical Director was made aware of R2 order and missed administration. Medical Director did not wish to order Caladryl based on current clinical presentation. 2) Director of nursing or designee audited not administered medication pass of current residents to ensure current medications are available to be administered, with no delay in medication administration. 3) Director of nursing or designee educated licensed staff on policy for ordering medications from pharmacy. 4) The Director of nursing or designee will audit medication administration records for missed doses, ensuring availability of medication 5 times per week for 2 weeks, and then monthly until compliance is met. Results of audits will be reviewed in QAPI each month until compliance is met. UPDATE: Education will include the path to follow if a medication is not available: Make RN aware, check MedBank, contact pharmacy, notify physician, follow physician orders, document, and notify family if applicable. Pharmacy does notify if a medication is unavailable.