Failure to Administer Prescribed Controlled Medications Due to Policy and Communication Breakdowns
Penalty
Summary
Facility administration failed to implement and enforce policies and procedures for medication administration, resulting in residents not receiving prescribed controlled medications, specifically Alprazolam, as ordered by their physicians. Three residents with histories of Alprazolam use were affected: one was admitted with a prescription for Alprazolam four times daily but experienced a delay of nine missed doses, leading to withdrawal symptoms such as sweating, shaking, insomnia, and increased pain. Another resident, prescribed Alprazolam once daily, did not receive the medication for three days after admission, and a third long-term resident missed three doses of their twice-daily Alprazolam prescription. In each case, there was no documentation of physician notification regarding the unavailability of the medication, and progress notes did not reflect any communication or intervention related to the missed doses. Interviews with nursing staff revealed a lack of awareness about the availability of Alprazolam in the facility's automated medication dispensing system. Several LPNs stated they were unaware that the medication could be accessed from the system and did not know the procedures for obtaining it in the absence of a pharmacy delivery. Staff also failed to notify physicians or nurse practitioners when medications could not be administered, as required by professional standards and facility policy. The DON acknowledged that staff should have called the provider and documented the situation but confirmed that this was not done. The facility's policy required staff to search for medications, contact the pharmacy, and notify the physician if a vital medication was unavailable, but these steps were not followed. The deficiency was further compounded by inadequate staff training and oversight. The DON and Administrator admitted that staff were not properly oriented to the medication distribution system, and there was no regular auditing of medication administration or staff competency regarding the use of the automated dispensing system. The Medical Director and pharmacist confirmed that Alprazolam was available in the emergency drug kit and could have been administered if staff had followed proper procedures. The lack of communication, documentation, and adherence to policy resulted in residents experiencing unnecessary discomfort and withdrawal symptoms due to missed doses of essential medication.