Delayed Medication Delivery Due to Incomplete Orders and Pharmacy Process Failures
Penalty
Summary
The facility failed to provide pharmaceutical services in a timely manner for one resident, as evidenced by repeated delays in the delivery and administration of prescribed medications following hospital discharge. Upon admission, the resident had incomplete physician orders for Fosinopril, Metoprolol Succinate, and Mirtazapine, with instructions listed as 'See instructions' and lacking specific dosage, route, or administration times. Facility staff did not clarify these orders promptly, resulting in delays in both order clarification and medication delivery. The pharmacy did not provide the medications according to the start dates indicated in the clarified physician orders, with Fosinopril not available until several days after the intended start date, and similar delays for Metoprolol Succinate and Mirtazapine. Documentation shows that staff signed off on medication deliveries days after the orders were clarified and after the medications were due to be administered. Interviews and record reviews revealed that both nursing staff and pharmacy personnel failed to follow established procedures for obtaining and delivering medications, especially outside of regular pharmacy hours. The facility's corporate nurse consultant acknowledged that staff did not clarify the incomplete hospital discharge orders in a timely manner and did not utilize the pharmacy's after-hours process to obtain urgently needed medications. The pharmacy's hours of operation and procedures for STAT orders were not effectively followed, contributing to the delay in providing necessary medications to the resident.