Failure to Provide Timely Medication Administration Due to Prescription Delays
Penalty
Summary
The facility failed to ensure that a resident's medications were available and administered as ordered upon admission. The resident, who had a history of chronic pain management with methadone and Lyrica, did not receive these medications for several days after admission due to the lack of a valid prescription. The resident's wife reported that he missed his medications for three days and expressed concern about potential withdrawal, particularly because he had been on methadone for 13 years. Nursing staff confirmed that the medications were not available and documented missed doses in the medication administration record (MAR). The delay in medication administration was attributed to the absence of signed prescriptions from the hospital at the time of admission. The facility's process required a signed script from a physician before the pharmacy could dispense the medications. Staff attempted to obtain the necessary prescriptions by contacting both the hospital and the facility's medical director. The hospital declined to provide the scripts, and the facility's medical director eventually signed them after being notified. During this period, the resident missed multiple doses of methadone and Lyrica, as documented in the MAR and progress notes. Additionally, upon discharge, the resident did not receive a prescription for a diuretic (Bumetanide), resulting in missed doses at home until a home health nurse intervened. The facility's medication reconciliation policy outlined steps to ensure continuity of medication administration during transitions, but these procedures were not effectively followed, leading to interruptions in the resident's prescribed medication regimen.