Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medication and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to meet the needs of a resident who was readmitted with diagnoses including diabetes and chronic anxiety disorder. Upon admission, the resident had an active order for lorazepam 2 mg orally twice daily, as documented in the hospital discharge summary and confirmed by the attending physician. However, the medication was not available for administration, and nursing staff documented multiple missed doses over a two-day period, noting that the resident was a new admit and the facility was waiting for pharmacy delivery. The delay in receiving lorazepam was due to a series of communication and procedural errors between the facility and the pharmacy. The pharmacy received the prescription but had the resident profiled under independent living rather than the skilled nursing facility, resulting in a lack of necessary allergy information and confusion about the resident's location. Additionally, the pharmacy could not release lorazepam from the emergency medication box because the available formulation (0.5 mg) did not match the physician's order (1 mg or 2 mg), and regulations required an exact match between the prescription and the medication formulation in the E box. As a result of these failures, the resident missed four doses of lorazepam and subsequently experienced a seizure, requiring transfer to the hospital. Documentation from the hospital confirmed that the resident had missed several doses of her chronic lorazepam regimen for unclear reasons, and the facility's records indicated that the medication was delivered only at the time the resident was experiencing a medical emergency and was unable to swallow.