Failure to Provide Timely Medications and Incomplete Narcotic Reconciliation
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of residents, as evidenced by multiple instances where residents did not receive their prescribed medications as ordered. For one resident with a physician's order for a daily Nicotine Transdermal Patch, medical record review showed repeated missed doses due to delays in reordering and pharmacy delivery. Nursing notes and the Medication Administration Record (MAR) documented several occasions over multiple months where the patch was not available, and staff interviews confirmed that medications were not always reordered in a timely manner, sometimes due to lapses in communication between staff members responsible for medication administration and reordering. Another resident with a complex medical history, including bacteremia and sepsis, did not receive prescribed IV Vancomycin on several occasions because the medication was not available from the pharmacy or in the facility's automated dispensing system. Documentation in the MAR and nursing notes confirmed missed doses and delays in pharmacy delivery, with blank spaces and notations indicating the medication was not administered. A third resident, admitted with conditions such as hypertension and acute kidney failure, also experienced missed doses of blood pressure medication due to unavailability, as documented in the MAR and confirmed by staff interviews. The facility's own Medication Reordering Policy required nurses to reorder medications when six or fewer doses remained, but staff and leadership acknowledged ongoing issues with timely reordering and medication availability. Additionally, the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at each change of shift, as required for controlled substances. Review of narcotic and controlled substance log binders for all medication carts revealed numerous missing signatures from both oncoming and off-going nurses across multiple shifts and halls. Staff interviews and facility policy confirmed that both nurses were expected to sign off on the narcotic count at each shift change, but this was not consistently done, resulting in incomplete documentation and lack of accountability for controlled medication storage and administration.