Failure to Provide Ordered Medication and Ensure Pharmaceutical Services
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to ensure that a resident received their prescribed medication, Ingrezza (Valbenazine), as ordered by their physician. The resident, who had diagnoses including congestive heart failure, morbid obesity, drug-induced subacute dyskinesia, and major depressive disorder, was admitted with an order for Ingrezza 40 mg daily for Tardive Dyskinesia. The medication was not administered on one occasion and then missed for a consecutive twelve-day period, totaling thirteen missed doses. There was no documentation in the resident's medical record explaining why the medication was not given, nor any evidence that the pharmacy or physician was notified during these missed doses. Further issues arose when the resident's Ingrezza dose was increased to 60 mg daily. The facility was unable to obtain the correct dose from the pharmacy, and the resident continued to receive the lower 40 mg dose for several days. Nursing notes indicated attempts to contact the pharmacy and the physician, but the correct dose was not provided, and the resident did not receive the ordered medication as prescribed. There was also a lack of documentation regarding physician notification or involvement of the medical director when the facility could not resolve the medication issue. Interviews with nursing staff revealed that the facility was experiencing challenges with agency nurses and charting, which contributed to the lack of documentation and follow-up. The staff confirmed that the resident did not receive the correct dose of Ingrezza and that there was no escalation to the medical director when the physician could not be reached. These actions and inactions resulted in the resident not receiving their medication as ordered, with insufficient documentation and communication regarding the missed doses.