Failure to Provide Ordered Routine Medication Due to Pharmacy Service Issues
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident who required routine physician-prescribed medication. Following a change in the resident's medication regimen, the facility did not obtain the ordered medication, Geodon 40 mg, resulting in multiple missed doses over several days. Documentation in the Medication Administration Record and nurse's progress notes repeatedly indicated that the medication was unavailable or not in stock on specific dates. The resident's diagnoses included anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, and the resident was noted to have moderately impaired cognitive skills and was rarely to never understood. Interviews with staff revealed ongoing difficulties in obtaining the medication from the pharmacy, attributed in part to the resident's payor source. Nursing staff reported that when a routine medication was unavailable, they were expected to check the emergency drug kit, document missed doses, and notify the physician. Despite these procedures, the resident did not receive the prescribed medication as ordered, and the facility's policy required contacting the pharmacy and using after-hours emergency numbers if necessary. The deficiency was identified through record review and staff interviews, confirming that the facility did not ensure the resident received all ordered medications.