Failure to Provide Timely Pharmacy Services for Newly Admitted Residents
Penalty
Summary
The facility failed to provide timely pharmacy services to meet the medication needs of two residents following their admission from the hospital. Both residents were admitted with specific medication orders for serious conditions, including a foot infection with osteomyelitis and COPD for one resident, and seizures with pneumonia for the other. Upon review, it was found that the required medications, such as Vancomycin and Augmentin, were not administered as ordered due to delays in obtaining them from the pharmacy. The facility's medication dispensing system did not have these medications available, and the pharmacy used by the facility was not local, resulting in further delays. Interviews with staff, including an LPN and the DON, revealed that the process for entering medication orders into the facility's system sometimes resulted in start times being set for the following day if entered after a certain hour. This contributed to the missed doses, as the medications were not available in the facility and were not delivered in time for administration. The DON acknowledged that it was the nurses' responsibility to obtain information about the last dose given at the hospital and to ensure medications were administered as ordered, but this did not occur for the two residents in question. The administrator confirmed that the facility admitted residents without ensuring the immediate availability of their required medications and that pharmacy services were not able to provide the ordered medications in a timely manner. Both residents missed critical doses of their prescribed medications, and this failure was acknowledged by facility leadership as a deficiency in providing necessary pharmaceutical services.