Failure to Ensure Timely Re-Ordering and Availability of Diabetes Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diabetes by not ensuring the availability of a prescribed medication, Farxiga. The resident, who was cognitively intact and required daily Farxiga for diabetes management, did not receive her scheduled dose because the medication was not in stock. Interviews with staff revealed that the medication aide was responsible for re-ordering medications but did not do so in a timely manner, resulting in the medication being unavailable when needed. The LVN and DON confirmed that the medication should have been re-ordered when only a few doses remained, but this process was not followed. Record reviews indicated that the resident's care plan included administering medications as ordered to manage her diabetes and prevent hyperglycemic or hypoglycemic episodes. The facility's policies required staff to order and receive medications according to standard practice guidelines, but these procedures were not adhered to in this instance. The DON acknowledged that the resident's insurance only allowed a 14-day supply of the medication, which required more frequent re-ordering, but staff failed to ensure the medication was ordered and received in time.