Failure to Provide Timely Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed for two residents. One resident had an order for Tramadol HCl 50 mg every 4 hours for pain, but missed three doses due to the medication being unavailable. Documentation showed that the medication was not available from the pharmacy or the Pyxis emergency medication supply, and no emergency prescription was sent to facilitate access. The Director of Nursing confirmed that the pharmacy did not provide an override code for the Pyxis, and the facility did not use a local pharmacy to obtain the medication because the primary pharmacy had already scheduled delivery for later that day. Another resident had orders for Dexlansoprazole 60 mg and Pantoprazole 40 mg, both used to treat GERD. This resident missed a total of nine doses of Dexlansoprazole and six doses of Pantoprazole over several days due to the medications being on order or not available. The EMAR documented each missed dose, and the Director of Nursing confirmed the missed administrations. These failures resulted from the facility's inability to obtain and provide the necessary medications as ordered by the residents' physicians.