Failure to Promptly Notify Facility of High-Priority Medication Discrepancy
Penalty
Summary
A deficiency occurred when the pharmacy failed to promptly notify facility staff of a high-priority clinical recommendation regarding a resident's antibiotic orders following hospital discharge for sepsis due to pneumonia. The resident, who had chronic respiratory failure with hypoxia, congestive heart failure, and COPD, was discharged from the hospital with orders to continue antibiotics (cefdinir and doxycycline) for pneumonia. The pharmacy's medication review identified that these antibiotics were not active in the facility's computer system and that the current hospital discharge orders had not been re-entered, but this information was not communicated to the facility in a timely manner. Although the pharmacy's policy required that priority recommendations be called in for immediate response, there was no evidence that the facility was notified by phone. The pharmacy consultation report was sent via email and not seen by the Director of Nursing until several days later, resulting in the resident not receiving the prescribed antibiotics from the time of readmission until the orders were clarified and entered. Interviews with facility staff and the consultant pharmacist confirmed that the lack of timely notification contributed to the delay in administering necessary medications.