Failure to Provide Timely Medication Administration for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a newly admitted resident received medications as ordered by their provider. The resident, who had diagnoses including hypertension, COPD, and a urinary tract infection, had physician orders for several medications to treat both chronic and acute conditions. Despite these orders, the resident did not receive multiple scheduled doses of Spiriva, Symbicort, Diltiazem, and Cefpodoxime as documented in the Medication Administration Record (MAR) and corresponding nursing notes, which indicated the medications were not available and were pending arrival from the pharmacy. Facility policies required that when medications were not available, nursing staff should contact the prescriber for directions and request STAT delivery from the pharmacy if needed. The pharmacy confirmed that the medication orders were received after regular hours and that a STAT order could have resulted in delivery within four hours, but no such request was made by the nursing staff. Nurses reported not administering the medications because they were not available in the facility’s medication storage and did not contact the pharmacy for STAT delivery, expecting the medications to arrive with the next scheduled delivery instead. Interviews with facility staff, including nurses, the unit manager, and the director of nursing, confirmed that the process for obtaining new admission medications was not followed as per policy. The staff did not contact the pharmacy for STAT delivery or notify the provider to discuss alternative medications when the ordered medications were unavailable. There was no documentation to show that the provider was contacted regarding the unavailability of the medications or to consider alternative treatments.