Failure to Provide Timely Pharmaceutical Services and Medications
Penalty
Summary
The facility failed to provide routine drugs and biologicals to meet the needs of three residents, as required by policy and regulation. For one resident admitted with orbital eye cellulitis and lower back pain, there were missed doses of IV antibiotics and pain medications due to unavailability upon admission. The medication administration record (MAR) documented four missed IV antibiotic doses and several missed doses of morphine-based pain medications, with notes indicating the medications were unavailable. Nursing progress notes showed that the provider was not notified of the missed doses until the following day, and the pharmacy later reported that one medication was on backorder, leading to a change in the pain management plan. Another resident, admitted with malignant neoplasm of the prostate and generalized weakness, had a physician order for Casodex that was not administered for two scheduled doses due to unavailability. The MAR reflected these missed doses, and corresponding notes indicated the medication was not available on the first two days after admission. Similarly, a third resident with epilepsy and multiple sclerosis did not receive two scheduled doses of Lacosamide, an anti-seizure medication, because the medication was not delivered with the initial pharmacy shipment. Nursing notes confirmed the delay and documented communication with the provider and pharmacy regarding the missing medication. Interviews with staff, including a registered nurse, the Nursing Home Administrator (NHA), and the Director of Nursing (DON), revealed ongoing issues with delayed medication deliveries and order discrepancies. Staff acknowledged that it was their responsibility to address these issues with the pharmacy and provider when discovered. Facility documentation showed scheduled pharmacy deliveries, but the NHA and DON were unable to provide specific reasons for the delays or documentation of delivery discrepancies. The DON noted that an alternative dose of a medication was available onsite but was not utilized because the provider was not contacted promptly.