Failure to Provide Timely Access to Ordered Medications
Penalty
Summary
Facility staff failed to ensure that ordered medications were available and administered as prescribed for three residents. For one resident with multiple diagnoses including neuropathy, diabetes, Alzheimer's disease, and atrial fibrillation, an order for Rocephin (Ceftriaxone Sodium) to treat a suspected urinary tract infection was not fulfilled because the medication was not available in the in-house supply. Staff used the last available dose, and subsequent attempts to obtain the medication from the Cubex system were unsuccessful. The pharmacy was not restocked in a timely manner, and the medication was placed on hold until it arrived, resulting in a missed dose. Another resident with diagnoses such as diabetes, obstructive and reflux uropathy, hypertension, and atrial fibrillation did not receive a one-time ordered dose of Ceftriaxone Sodium (Rocephin) as scheduled. The medication was not available in the Cubex system at the time of administration, and the dose was delayed until it could be obtained from the pharmacy. Facility policy indicated that a STAT supply of commonly used medications should be maintained in-house, but this was not followed in these instances. A third resident, with a history of femur fracture, chronic atrial fibrillation, restless leg syndrome, and osteoarthritis, did not receive two scheduled doses of Lyrica for pain management because the medication was not available. Nursing notes documented calls to the pharmacy and provider to obtain a new prescription and indicated that the medication was on order and awaiting delivery. The care plan for this resident included medicating as ordered for comfort, but the medication was not administered as prescribed due to unavailability.