Failure to Ensure Timely Availability and Administration of Medications for New Admission
Penalty
Summary
The facility failed to ensure that medications for a newly admitted resident were available for timely administration. The resident, who was admitted with orders for Carvedilol and Entresto to be given twice daily for hypertensive heart disease with heart failure, did not receive all prescribed medications as scheduled. Although most medications were delivered early in the morning, Entresto was not delivered, and Carvedilol was marked as unavailable for the 5:00 PM dose on the day of admission. The Medication Administration Record (MAR) indicated that the 5:00 PM dose of Entresto was not administered until 10:20 PM, and there was no corresponding note explaining the delay for Entresto, while Carvedilol was documented as unavailable. Interviews with facility staff revealed that if a medication is not available in the emergency medication supply (stat-safe), it should be ordered STAT from the pharmacy, and the prescriber should be contacted if there is a delay. The facility's policy requires that emergency or STAT orders be filled and administered as soon as received or within two hours. However, these procedures were not followed, resulting in delayed administration of critical medications for the resident upon admission.