Failure to Ensure Timely Acquisition, Administration, and Accounting of Resident Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not ensuring the timely acquisition, dispensing, and administration of medications for three residents. For one resident, multiple essential medications, including those for hyperlipidemia, atrial fibrillation, diabetes, neuropathy, and pain, were not administered upon admission and for several days thereafter. The missed doses were due to a combination of factors: the admitting nurse did not have access to the emergency medication supply, pharmacy cut-off times delayed delivery, and a required prescription for a controlled substance was not obtained until several days after admission. Documentation on the Medication Administration Record (MAR) showed repeated missed doses, and interviews with staff revealed confusion about procedures for accessing backup medications and obtaining necessary prescriptions. Another resident was readmitted to the facility from another rehabilitation center and did not receive newly ordered medications, including a blood pressure medication and an antibiotic, for several days after readmission. The nurse on duty did not reconcile the new transfer orders with existing orders in the electronic system, resulting in a failure to order and administer the required medications. The pharmacy also delayed dispensing an antibiotic due to a potential drug interaction and the need for staff consultation, further contributing to missed doses. Documentation and interviews confirmed that the resident missed several scheduled doses of both the blood pressure medication and the antibiotic before they were finally administered. A third resident supplied her own medication from home, but the facility failed to maintain an effective system for accounting for this medication. The resident's home-supplied medication was not administered during her stay, and upon discharge, she was given another resident's medication in error. The resident reported the issue to facility management, but her medication was not returned, and she remained in possession of another resident's medication. Staff interviews confirmed a lack of documentation and tracking for medications brought in by residents, and the Director of Nursing acknowledged that procedures for handling such medications were not followed.