Failure to Provide Timely Pharmaceutical Services for New Admissions
Penalty
Summary
The facility failed to ensure that newly admitted residents received their prescribed medications in a timely manner, resulting in multiple residents experiencing significant delays in pain management and other essential medications. Several residents reported not receiving their pain medications for up to two days after admission, despite having active orders for medications such as methadone, morphine, baclofen, gabapentin, oxycodone-acetaminophen, and pregabalin. Documentation in the Medication Administration Records (MAR) and interviews with residents and staff confirmed that medications were marked as unavailable, and residents experienced high levels of pain during this period. In some cases, only over-the-counter acetaminophen was administered, which residents reported as ineffective for their pain levels. Interviews with nursing staff revealed a lack of awareness and training regarding the use of the facility's electronic medication dispensing machine and backup pharmacy services, particularly during weekend admissions. Staff reported waiting for medications to arrive from the pharmacy and did not consistently utilize available emergency drug supplies or contact prescribing providers for alternative orders. There was also a lack of communication with the pain management physician and medical director regarding the unavailability of medications, and no evidence that responsible parties or providers were notified when medications were not administered as ordered. In addition to pain medications, at least one resident did not receive prescribed antihypertensive medications for two days, with documentation indicating the drugs were not available and the pharmacy had been notified. The facility was unable to provide a policy and procedure for pharmacy services when requested. The deficiency was further compounded by the facility's lack of a systematic process to ensure medication availability and administration upon admission, especially during weekends, as acknowledged by the nursing home administrator and consultant pharmacist.