Failure to Timely Obtain and Administer Medications from Pharmacy
Penalty
Summary
The facility failed to ensure that medications were obtained and available from the pharmacy in a timely manner to meet the needs of residents. For one resident admitted with multiple diagnoses including cellulitis, diabetes, hypertension, and depression, a review of the Medication Administration Record showed that numerous prescribed medications, such as antihypertensives, antidepressants, diabetes medications, and IV antibiotics, were not administered on the day of admission due to unavailability from the pharmacy. The resident reported feeling unwell, experiencing nausea and pain, and was unable to participate in therapy or personal care activities as a result of not receiving her medications. Another resident, admitted with diagnoses including skin infection, peripheral vascular disease, diabetes, and COPD, did not receive several ordered medications, including an antidepressant, anticonvulsant, and IV antibiotic, because they were not available from the pharmacy. Interviews with nursing staff confirmed that it was not uncommon for new admissions to experience delays of up to a day and a half before medications arrived from the pharmacy, particularly for medications not stocked in the automated dispensing system. The Director of Nursing verified that missed doses occurred due to medication unavailability. Facility policy required the pharmacy to supply and deliver needed medications, but this was not consistently achieved.