Failure to Provide Timely Pharmacy Services Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmacy services to meet the needs of a resident who was readmitted with diagnoses including traumatic brain injury and epilepsy. Upon review, it was found that the resident had physician orders for multiple anti-seizure medications, including Clobazam, Lacosamide, and Zonisamide, all to be administered via gastrostomy tube. However, the medication administration record showed that these medications were not given on several days following the resident's readmission. Progress notes confirmed that the medications were not available at the facility and were pending delivery from the pharmacy. Interviews with facility staff and the consultant pharmacist revealed that delays occurred due to the need for triplicate prescriptions for controlled substances and a lack of timely delivery authorization for a high-cost medication. The pharmacy had requested the necessary documentation and authorizations from both the physician and the facility, but did not receive them in time to ensure the medications were available as ordered. Facility policies required timely receipt and administration of medications, but these were not followed, resulting in the resident not receiving prescribed anti-seizure medications as ordered.