Failure to Provide Timely Pharmaceutical Services for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of two residents upon admission, resulting in missed medication doses as ordered by their physicians. For one resident with hypomagnesemia, physician orders for magnesium supplements were not fulfilled for several consecutive days, as documented in the electronic medication administration record (EMAR) and progress notes. Staff repeatedly noted that the medication was on order or unavailable, and there was no documentation that the resident was notified of the missed doses or assessed for symptoms related to low magnesium levels, despite a critical lab result indicating hypomagnesemia. Another resident admitted with COPD and depression did not receive prescribed medications for depression and respiratory management on two occasions, as the medications were not available in the facility or from the pharmacy. Progress notes indicated the medications were on order and not yet delivered, with no documentation of resident notification or assessment for adverse outcomes. Interviews with staff confirmed that medications were not administered as ordered and that appropriate follow-up actions, such as timely notification of providers or use of emergency supplies, were not consistently documented or performed.