Failure to Provide Timely Controlled Medications Due to Pharmacy and Staff Oversight
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of two residents who required controlled medications for anxiety and pain management. One resident, admitted with diagnoses including seizures, aphasia, and deaf non-speaking, had a severely impaired cognitive status and was prescribed lorazepam for anxiety. Despite having a physician's order for lorazepam, multiple doses were not administered over several days due to delays in obtaining the medication from the pharmacy. Documentation in the electronic medical record indicated repeated notes of waiting for pharmacy delivery, and nursing staff confirmed the resident did not refuse the medication. Although lorazepam was available in the facility's emergency medication supply, it was not utilized to prevent missed doses. Another resident, admitted with a history of joint replacement and osteoarthritis, was prescribed tramadol for pain management. This resident, who was cognitively intact, reported to nursing staff that he had been without his pain medication for over two days. Nursing staff confirmed the medication had not been delivered and had not been administered as ordered. The facility had a process in place to access emergency medication supplies (Pyxis machine) in such situations, but this process was not followed, resulting in the resident not receiving pain medication as needed. Interviews with nursing staff and facility administration revealed a lack of awareness and follow-through regarding the availability and administration of these controlled medications. Staff acknowledged that procedures existed to obtain medications from emergency supplies when routine deliveries were delayed, but these procedures were not implemented. The facility's own policy required staff to check for pharmacy communications and contact the pharmacy for missing medications, but this was not effectively carried out, leading to missed doses for both residents.