Failure to Ensure Timely Availability of Routine Medications for New Admission
Penalty
Summary
The facility failed to ensure the timely availability of routine medications for a newly admitted resident with diagnoses including rheumatoid arthritis, weakness, and depression. Upon admission from a hospital, the resident had physician orders for Alrex eye drops, Pregabalin, and Duloxetine. Multiple doses of these medications were not administered as indicated by missing checkmarks and staff initials on the Medication Administration Record (MAR), with corresponding progress notes documenting that the medications were not available at the facility. The facility's policy outlined the process for obtaining medications from the pharmacy but did not address steps to take if medications did not arrive as expected. Progress notes and staff interviews confirmed that the medications were not available for several scheduled doses, and there was no documentation that staff contacted the pharmacy to follow up on the missing medications. The resident ultimately left the facility against medical advice. Staff interviews revealed a lack of clarity and action regarding obtaining the missing medications, with one RN stating she had received education to call the provider but had previously waited for the pharmacy. The DON stated that staff could request a stat delivery or contact the provider for orders, but this was not documented as having occurred during the incident.