Deficiencies in Pharmaceutical Services: Medication Availability, Administration, and Controlled Substance Accountability
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in multiple deficiencies related to medication availability, administration, storage, and accountability. On several occasions, a resident did not receive prescribed Lovenox injections due to pharmacy delivery delays, as documented in medication administration records and confirmed by both staff and the resident. The medication was unavailable for administration on six separate occasions, with staff noting the absence and pharmacy follow-up in progress notes. There were also failures in the administration of glipizide for two residents with diabetes. The medication was not given according to the physician's orders or manufacturer’s specifications, with doses scheduled and administered after meals instead of before, as required for optimal therapeutic effect. This was confirmed through review of medication administration records, meal schedules, and interviews with the Director of Nursing, who acknowledged the discrepancy and the error in order entry. The facility did not maintain accurate accountability for controlled substances. In multiple instances, controlled medications were signed out of the controlled drug record but not documented on the medication administration record for several residents. Discontinued or expired controlled substances were found in medication carts and the medication room, accessible to multiple staff and not counted during shift changes. Duplicate narcotic emergency drug kits were present, and opened emergency kits were not replaced in a timely manner. Additionally, staff did not consistently document emergency kit checks between shifts, and logs showed numerous missed entries. These findings were confirmed by staff and the Director of Nursing during inspections and interviews.