Failure to Timely Re-Order and Provide Medications
Penalty
Summary
The facility failed to re-order medications in a timely manner for one resident, resulting in the unavailability of three prescribed medications: Glipizide and Metformin (both for diabetes) and Trazodone (an antidepressant). The resident, who has a medical history of diabetes mellitus, multiple sclerosis, and cerebral infarct, reported not receiving all her medications, including eye drops and diabetes medication. Upon review of the medication cart with a registered nurse, it was confirmed that these medications were not available at the time of observation. Facility staff, including the Assistant Director of Nursing and the registered nurse, acknowledged that medications should be re-ordered when the bingo card indicator reaches the dark blue area, which corresponds to eight doses remaining. The facility's policy requires staff to request refills from the pharmacy 72 hours before the last dose. However, the nurse stated that the re-order for Glipizide and Metformin was only placed on the day of the observation, indicating a failure to follow the established policy and ensure timely medication availability for the resident.