Failure to Document Receipt of Pharmacy-Delivered Medications by Licensed Staff
Penalty
Summary
The facility failed to follow its own Policy and Procedure regarding the receipt and documentation of medications delivered by the pharmacy for three sampled residents. Specifically, licensed staff did not check, sign, date, or time the receipt of medications for these residents as required by the facility's policy. This was confirmed through interviews with nursing staff and a review of the Prescription Delivery Receipt records, which showed missing signatures, dates, and times for the medications received. The residents involved had significant medical histories, including morbid obesity, history of falls, acute respiratory failure, end stage renal disease, chronic obstructive pulmonary disease, osteoarthritis, and major depressive disorder. Each resident had active medication orders, such as topical antifungals, inhalation solutions, and oral antibiotics, which were not properly documented upon receipt. Staff interviews confirmed that the expected process was not followed, and the required documentation was absent from the records for these residents.