Failure to Provide Prescribed Medication Due to Pharmacy Service Lapse
Penalty
Summary
The facility failed to obtain and provide a prescribed medication, Ingrezza, for a resident with a history of schizoaffective disorder. Upon admission, the resident's hospital discharge records indicated the need to continue Ingrezza 40 mg nightly. However, nursing documentation showed that the pharmacy did not supply the medication, and instead, the resident's sister was expected to bring it in. There was no documentation explaining why the pharmacy was not contacted or able to provide the medication, and the Ingrezza was the only medication not obtained through the facility's pharmacy. Review of the Medication Administration Record (MAR) revealed that nursing staff did not administer the resident's nightly Ingrezza on multiple occasions, documenting that the medication was not available from the pharmacy or not found in the medication cart. Further nursing notes indicated ongoing communication with the resident's sister regarding the medication, but no evidence was found that the pharmacy was contacted to resolve the issue. These findings were confirmed by a registered nurse during an interview.