Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide routine and emergency medications as ordered for two residents, resulting in missed doses of critical medications. One resident, a male with multiple complex diagnoses including metabolic encephalopathy, chronic inflammatory demyelinating polyneuritis, and a recent lumbar fracture, was admitted and did not receive nine prescribed medications on the day of admission. These included anticoagulants, antiarrhythmics, antihypertensives, and other essential medications. Documentation showed that the medications were not received from the pharmacy in time, and there was a lack of clear communication among staff regarding the availability and administration of these medications. The resident's care plan required administration and monitoring of these medications, but the medications were not administered as ordered, and the reasons for the missed doses were not clearly documented in the progress notes. Another resident with end-stage kidney disease and dependence on hemodialysis did not receive a prescribed phosphate binder, Sevelamer Carbonate, for a total of 41 missed doses over several weeks. The medication was not available due to insurance coverage issues and a change in responsibility for ordering the medication, which led to a gap in supply. Nursing staff identified the issue but did not consistently follow up or communicate effectively with the pharmacy, dialysis center, or physician. The resident's care plan required administration of medications as ordered and monitoring for side effects, but the medication was placed on hold without clear documentation of who authorized this action. Laboratory results showed elevated phosphate levels during the period when the medication was not administered. Interviews with facility staff revealed inconsistent practices regarding the process for obtaining and administering medications, as well as unclear lines of communication and responsibility. Staff were not always aware of missed doses or the procedures to follow when medications were unavailable. Facility policies required timely administration of medications and specific actions when medications were missed, but these procedures were not consistently followed for the residents involved.