Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to ensure the timely provision and administration of routine and emergency medications for two residents, resulting in missed doses of critical medications. For one resident with schizophrenia and a physician order for Lithium Carbonate, the medication was not administered on multiple occasions because it was not available in the automated medication dispensing machine. The pharmacy had rejected refill requests due to a computer error, and facility staff did not follow up with the pharmacy to resolve the issue. As a result, the resident's Lithium blood level was found to be low, and the resident was subsequently transported to the hospital at the family's request after concerns about symptoms were raised. Another resident with end stage renal disease, diabetes, and malnutrition did not receive prescribed medications, including cinacalcet and Sevelamer, for an extended period after admission. The medications were not available in the facility, and there was confusion regarding whether they would be provided by the dialysis center or needed to be obtained from the facility's pharmacy. Multiple nurses documented that the medications were not available and reported the issue to supervisors, but the medications were not obtained in a timely manner. The pharmacy did not fill the medications until several days after the resident's admission, and the resident missed numerous doses as documented in the Medication Administration Record. Interviews with nursing staff and pharmacy personnel confirmed that the facility's process for ordering, tracking, and ensuring the availability of medications was not followed as required by policy. Staff did not consistently notify the pharmacy or medical provider when medications were unavailable, and there was a lack of timely follow-up to resolve issues with medication procurement. These failures resulted in residents not receiving essential medications as ordered by their physicians.