Failure to Provide Prescribed Anti-Convulsant Medications Due to Pharmacy Supply Issues
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of epilepsy did not receive prescribed anti-convulsant medications as ordered by their provider. The resident had physician's orders for Oxcarbazepine and Lamotrigine, both used to treat seizures, with specific dosages and administration times. Review of the Medication Administration Record (MAR) for the month showed multiple instances where the resident did not receive these medications, with nurses documenting that the medications were not available and noting 'on order' or similar explanations in the nursing progress notes. Nursing staff reported that they contacted the pharmacy when medications were unavailable, but there was no documentation of further steps taken to ensure the medications were obtained. Interviews with nurses revealed ongoing issues with pharmacy supply, including delays in delivery, limited quantities being sent, and long wait times when contacting the pharmacy. Despite repeated calls and documentation of the issue, the resident continued to miss doses of their prescribed medications on several occasions. The Director of Nursing confirmed that the resident was not administered the prescribed doses of Oxcarbazepine and Lamotrigine because the medications were not available from the pharmacy. The facility's policy required that residents have a sufficient supply of medications and that nursing staff communicate with the pharmacy and take responsibility for obtaining medications when not available, but these procedures were not effectively followed in this case.