Delayed Physician Signature Causes Missed Medication Doses
Penalty
Summary
The facility failed to ensure that a physician signed medication orders in a timely manner, resulting in missed doses of a prescribed medication for one resident. The resident, who was admitted with diagnoses including polyneuropathy and congestive heart failure, was prescribed Pregabalin to manage neuropathic pain. The original prescription included 45 capsules with no authorized refills. When the medication supply ran out, staff contacted the physician's office multiple times to obtain a new signed order, as required for continued therapy. Despite assurances, the physician did not come to the facility to sign the order as expected. As a result of the delay in obtaining the physician's signature, the resident missed eight scheduled doses of Pregabalin over a three-day period. The delay persisted until a unit manager personally delivered the unsigned prescription to the physician's office and obtained the necessary signature. The facility's failure to secure timely physician authorization directly led to interruptions in the resident's prescribed medication regimen.