Failure to Administer Medications as Ordered During Pharmacy Transition
Penalty
Summary
Facility staff failed to administer medications as ordered by physicians for two residents out of a sample of five, in a facility with a census of 82. The facility's own policies required medications to be administered as ordered and within a specific time frame, but multiple doses of critical medications were missed for both residents. For one resident with complex medical conditions including osteomyelitis, hypertension, heart failure, atrial fibrillation, and chronic obstructive pulmonary disease, there were numerous missed doses of IV antibiotics, antihypertensives, anticoagulants, and other essential medications. Documentation showed that these medications were not available and not administered over several days, with some missed doses specifically noted as due to medication unavailability. The resident's medical records indicated significant health events during this period, including episodes of severe hypertension, lightheadedness, and a fall. Progress notes documented that the resident experienced elevated blood pressure readings, lightheadedness, and eventually required transfer to the hospital, where diagnoses included cerebellar infarct, acute kidney injury, and osteomyelitis. There was also a lack of nursing documentation regarding some of the elevated blood pressure readings and missed medication administrations. For another resident with vascular dementia, cervical disc degeneration, chronic kidney disease, and hypertension, there were also missed doses of prescribed medications, including donepezil and gabapentin, over several days. Interviews with staff revealed that the facility had recently changed pharmacies, resulting in delays and gaps in medication availability. Staff reported that the previous pharmacy supplied medications only through the end of the month, and the new pharmacy was unable to provide medications immediately due to insurance and supply issues. The facility did not have a secondary pharmacy or adequate emergency medication supplies to cover the transition period.