Failure to Timely Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that medications were obtained and administered in a timely manner, resulting in a resident missing prescribed doses of temazepam for insomnia. The resident, who was cognitively intact and had multiple diagnoses including lumbosacral spinal fusion, lumbar spine stenosis, anxiety, and breast cancer, did not receive temazepam as ordered on two consecutive nights. Documentation in the electronic medical record and medication administration record confirmed that the medication was not available and had not been administered as prescribed. Nursing staff noted that a script was required for the pharmacy to fill the temazepam order, but there was a lack of effective communication and follow-up with the providers to obtain the necessary prescription. The pharmacy account manager confirmed that the medication was not on the resident's profile, indicating the script was never received. The administrator acknowledged that the process should not have taken over 24 hours, but the resident ultimately did not receive the medication as ordered due to these lapses.