Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to obtain ordered medications in a timely manner for two residents, resulting in multiple missed doses of prescribed drugs and supplements. For one resident with diagnoses including Type 2 Diabetes, lumbago with sciatica, depression, and difficulty walking, the electronic medication administration record (eMAR) showed missed doses of bupropion, CoQ-10, prednisone, Tresiba, adult multivitamin gummies, and baclofen, all due to the medications not being available. For another resident with respiratory failure, persistent vegetative state, tracheostomy, paranoid schizophrenia, and gastrostomy, the eMAR documented missed doses of atropine sulfate, ciprofloxacin, cefepime, and diazepam, also due to drug unavailability. The deficiency was attributed to delays in transmitting medication orders to the pharmacy, lack of clear instructions in the pharmacy policy for obtaining non-controlled medications before routine delivery times, and staff not requesting access to the emergency medication supply for controlled substances. Additionally, there was no alternate pharmacy listed for urgent medication needs. These issues were confirmed by the Nursing Home Administrator during interviews, who acknowledged the delays and gaps in the facility's processes for ensuring timely medication delivery.