Failure to Provide Timely and Safe Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents by not ensuring timely administration and proper handling of medications as ordered by physicians. For one resident with severe cognitive impairment and poor appetite, the facility did not administer Marinol as ordered for eight days due to the medication not being available and waiting for pharmacy delivery. Nursing staff did not notify the physician within 24 hours of the medication's unavailability, as required by facility policy, resulting in 15 missed doses. Another resident, also with severe cognitive impairment and dependent on staff for daily activities, did not receive scheduled medications at the prescribed times. The medications, which included apixaban, spironolactone, finasteride, and bethanechol, were administered more than an hour after the scheduled time. The nurse acknowledged that the late administration could affect the resident's health, and the facility's policy allows for a one-hour window before or after the scheduled time, which was not adhered to in this case. A third resident, who had intact cognitive skills but required assistance with daily activities, was found with a medication cup containing two pills left on the bedside table after refusing to take them. The resident had not requested to self-administer medications, and facility policy prohibits leaving medications at the bedside. Staff interviews confirmed that medications should not be left unattended and should be properly documented and disposed of if refused.