Failure to Ensure Timely Refill of Anxiety Medication
Penalty
Summary
The facility failed to ensure that anxiety medication was available for a resident with diagnoses of post-traumatic stress disorder (PTSD) and anxiety. The resident reported feeling distressed and experiencing increased anxiety after running out of Xanax, which was prescribed as needed every eight hours for anxiety. The medication administration record confirmed that the resident missed two doses of Xanax when it was not available, and the next dose was not administered until the pharmacy delivered the medication later that day. Interviews with facility staff and the pharmacist revealed that the process for refilling controlled substances required nurses to print the refill request, obtain the physician's signature, and fax it to the pharmacy. Staff acknowledged that the refill order should have been placed when only two to three days of medication remained, but this was not done, resulting in the missed doses. The facility's policy also indicated that medications should be reordered in advance if not using an automated refill system. Staff confirmed that the failure to order the medication in a timely manner led to the resident missing doses of her prescribed anxiety medication.