Failure to Administer Medications as Ordered After Admission
Penalty
Summary
The facility failed to ensure that medications were administered as ordered in a timely manner for a newly admitted resident. Upon admission, the resident had multiple diagnoses including vesicointestinal fistula, peritoneal abscess, acute diastolic heart failure, hypothyroidism, arteriosclerotic heart disease, hypertension, and gastroesophageal reflux. Physician orders included several medications such as antibiotics, antidepressants, antihypertensives, and medications for thyroid and coronary artery disease. Despite these orders, the medication administration record showed that several medications, including fluoxetine, isosorbide, levothyroxine, metoprolol, omeprazole, and amoxicillin, were not administered as scheduled after admission. Interviews with nursing staff revealed that a computer system issue beginning two days prior to the resident's admission interfered with communication between the facility and the pharmacy regarding new medication orders. The facility's stock medication list indicated that several of the missed medications were available in the starter kit and could have been administered. The resident reported not receiving medications until several days after admission. The facility's pharmacy contract required daily delivery of prescriptions and 24/7 emergency pharmaceutical services, but these services were not effectively utilized to ensure timely medication administration for the resident.