Failure to Provide and Document Required Medications for Two Residents
Penalty
Summary
The facility failed to ensure the provision and documentation of routine and emergency medications for two residents, resulting in deficiencies related to pharmaceutical services. One resident, admitted with chronic obstructive pulmonary disease (COPD) and dyspnea, did not receive a physician-ordered as-needed (PRN) Ipratropium-Albuterol inhaler due to the medication being unavailable from the pharmacy. The resident reported not receiving the inhaler since admission, despite experiencing episodes of shortness of breath. Review of the Medication Administration Record (MAR) confirmed that the inhaler had never been administered, and nursing staff verified that the medication was not present in the medication cart. Interviews with nursing staff and the Director of Nursing (DON) revealed that the process for following up with the pharmacy and notifying the physician or responsible party about unavailable medications was not followed, and there was no documentation of alternative arrangements or communication regarding the missing medication. Another resident, admitted with sepsis, cellulitis, and a wrist fracture, was prescribed intravenous (IV) antibiotics following hospital discharge. Upon admission, the resident required immediate administration of IV Cefazoline, which was obtained from the Emergency Kit (E-kit) due to pharmacy delivery timing. However, the removal of the antibiotic from the E-kit was not documented in the medication log, pharmacy E-kit slips, or progress notes. Staff interviews confirmed that the required documentation process, which includes filling out pharmacy slips and logging the removal to notify the pharmacy for restocking, was not completed. The facility's policy and procedure required this documentation to ensure accurate record-keeping and timely replacement of emergency medications. Both deficiencies were confirmed through interviews with staff and review of facility policies, which outlined the required steps for medication ordering, receiving, and emergency kit management. The DON and Director of Staff Development acknowledged that the expected procedures were not followed in these cases, resulting in the unavailability of a prescribed inhaler for one resident and a lack of documentation for the use of an emergency antibiotic for another.