Failure to Provide Timely Physician-Ordered Medications Due to Pharmacy Delays
Penalty
Summary
The facility failed to provide physician-ordered medications in a timely manner to meet the needs of a resident. A resident with multiple diagnoses, including cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder, was admitted in May 2024. On July 17, 2025, a change in condition was noted when the resident developed redness in the left eye, and a new order for Polyethylene glycol eye drops was prescribed. Documentation in the electronic Medication Administration Record (eMar) indicated that the medication was not available and the facility was waiting for pharmacy delivery. Over the following days, additional notes confirmed that the medication had still not been delivered, and staff continued to document the delay. Interviews with the DON and nursing staff confirmed ongoing issues with the pharmacy's timely delivery of medications. The DON acknowledged repeated problems, especially on weekends, requiring escalation to corporate and personal intervention to obtain necessary medications. Nursing staff reported having to repeatedly contact the pharmacy and sometimes order medications STAT due to urgent resident needs. The NHA was also made aware of the ongoing concerns regarding medication delivery delays.