Failure to Ensure Timely Acquisition and Administration of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for three residents. For one resident with dementia, Xanax was not administered as ordered on multiple occasions due to the medication being unavailable; documentation showed delays in obtaining a new prescription and in communication with the pharmacy and physician. Another resident with atrial fibrillation and diabetes did not receive a prescribed dose of Macrobid because the medication was unavailable from the pharmacy, and the facility could not provide a reason for the unavailability. A third resident with unspecified dementia did not receive a scheduled dose of Oxycodone due to the need for a new prescription and unsuccessful attempts to obtain a release code from the pharmacy. Facility policy required nurses to check the Med Cubex inventory, contact the pharmacy for medication status, and notify the physician if a new order was needed. However, interviews with the DON and clinical nurse consultant confirmed that procedures were not adequately followed to ensure timely medication acquisition and administration. Documentation in the medication administration records and nursing notes consistently indicated medication unavailability and delays in obtaining necessary prescriptions or pharmacy codes, resulting in missed doses for the affected residents.