Delayed Administration of Prescribed Steroid Due to Allergy Flag and Communication Lapses
Penalty
Summary
The facility failed to provide a prescribed medication, methylprednisolone, to a resident in a timely manner following admission. The resident, who had a history of rheumatoid arthritis, Addison's disease, and adrenal suppression, was discharged from the hospital with a tapering dose of methylprednisolone. The medication was ordered on the day of admission, but was not delivered to the facility until four days later, and the resident did not receive the first dose until five days after the order was placed. Documentation in the Medication Administration Record and progress notes confirmed that the medication was not available and not administered as ordered during this period. The delay in medication administration was due to a flagged allergy to prednisone in the resident's record, which caused the pharmacy to place the order on hold pending clarification. The pharmacy did not make an outbound call for clarification after the initial order, and subsequent attempts by the facility to reorder the medication were also delayed due to the allergy flag. Communication between the facility and the pharmacy was inconsistent, with the pharmacy waiting for clarification and the facility staff following up multiple times before the medication was finally delivered and administered. Interviews with facility staff, including nursing management and the DON, revealed that the process for ensuring medication availability involved checking the emergency medication cabinet, contacting the pharmacy, and notifying the provider. However, in this case, the follow-up was not sufficiently aggressive to resolve the issue promptly. The resident reported not receiving the medication, and staff documented ongoing efforts to obtain it, but the medication was not provided as ordered until several days after admission.