Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Communication
Penalty
Summary
The facility failed to ensure timely follow-up with pharmacy services to fill new medication orders and refill standing orders before the supply was exhausted for a resident with multiple complex diagnoses, including ovarian cancer, schizoaffective disorder, and severe cognitive impairment. The resident, who was receiving hospice care, had physician orders for morphine sulfate ER and morphine sulfate oral solution for pain management. However, the morphine sulfate ER was not administered for several days after being ordered due to lack of availability, and the as-needed morphine solution was not given in its place. Documentation showed that the pharmacy had requested clarification on the order, but the facility did not respond promptly, resulting in missed doses. Additionally, the facility did not communicate with the pharmacy in a timely manner to ensure medication delivery before the supply was depleted. The resident also had a physician order for lorazepam intensol for agitation and pain, but missed multiple doses over several days due to the facility not requesting a refill in time and not requesting a STAT delivery when the supply ran out. Nurse documentation did not reflect that missed doses were reported to nursing supervisors or the provider as required by facility policy. Interviews with pharmacy representatives and the DON confirmed that the facility's lack of timely communication and follow-up led to the resident missing scheduled doses of both morphine and lorazepam.