Failure to Ensure Timely Availability of Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure physician-ordered medications were available for three of seven residents reviewed for medication availability. In one case, a family member reported that she is responsible for refilling a resident's medications from an outside pharmacy and that the facility sometimes runs out of medications without notifying her. Upon review of the medication cart, several of the resident's regularly scheduled and as-needed medications, including Ammonium Lactate cream, propylene glycol-glycerin eye drops, and Albuterol Sulfate inhalation aerosol, were not available. The LPN assigned to the resident confirmed that when medications are running low, nursing staff are supposed to inform the family member, but this was not consistently done. Another resident reported that the facility had previously run out of her pain medication, and a review of the medication cart revealed that several of her scheduled and as-needed medications, such as lidocaine cream, fluticasone-umeclidinium-vilanterol inhalation powder, guaifenesin, and hydrocortisone cream, were unavailable. The LPN assigned to this resident stated that medication refill requests can be made electronically or by fax, but had not reordered any medications that day. A third resident also reported previous shortages of her pain medication, and multiple scheduled and as-needed medications were found to be unavailable during the review. The DON stated that a three-day supply of medications should be maintained and that nurses are responsible for reordering medications and notifying family members in advance if a refill is needed. The facility's policy encourages electronic reordering of medications.