Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of its residents, resulting in missed doses of critical medications for two residents. One resident, admitted with a rare autoimmune disorder, type 2 diabetes, and carcinoma-in-situ of the lung, experienced multiple missed doses of Pyridostigmine Bromide ER, a medication essential for muscle strength. The missed doses were due to issues with prior authorization (PA) requirements, pharmacy communication lapses, and delays in medication delivery. Documentation showed that the resident went several days without the medication, leading to observable physical weakness and concern expressed by the resident. Staff interviews revealed confusion and inconsistent processes regarding PA notifications, ordering, and communication with the pharmacy, with changes in the pharmacy's notification system contributing to the problem. Another resident, with chronic kidney disease and neuropathic pain, missed 14 doses of gabapentin over several weeks. Despite staff attempts to reorder the medication and communicate with both the physician and pharmacy, the medication was not refilled in a timely manner. The resident reported increased pain and discomfort during the period without medication. Staff interviews indicated that the medication was not available in the emergency medication system, although the contracted pharmacy later stated it was. The facility's processes for medication reordering and emergency access were inconsistently followed, and communication barriers with the new pharmacy further delayed medication delivery. Review of facility policies confirmed that procedures were in place for reordering, administering, and documenting medications, but these were not effectively implemented. Staff described multiple methods for reordering medications, including electronic health records, fax, and manual logs, but there was no consistent or reliable system to ensure timely medication delivery, especially when prior authorizations were required. The facility's failure to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals resulted in unmet pharmaceutical needs for the residents involved.