Failure to Provide Timely Medications and Notify Physicians of Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring that ordered medications were available for administration and by failing to notify physicians when medications were unavailable. This resulted in three residents not receiving their prescribed medications as ordered. The facility's own policy required medications to be administered as ordered by the physician and in accordance with professional standards, but this was not followed in these cases. One resident with multiple chronic conditions, including multiple sclerosis, hypothyroidism, and restless legs syndrome, did not receive several medications for multiple days after admission. Documentation showed that doses of pantoprazole, venlafaxine, mirabegron, and ropinirole were not administered due to the drugs not being available. There was no documentation that the physician was notified of these missed doses. The resident reported not refusing any medications and expressed that missing these medications for several days would negatively affect their well-being. Another resident with a history of pulmonary embolism, hypertension, and congestive heart failure also did not receive several ordered medications, including antihypertensives, supplements, and an antifungal, due to unavailability. Again, there was no documentation of physician notification regarding the missed doses. A third resident, who had chronic pain following a leg amputation, did not receive pregabalin for several days because the prescription was not renewed in time and the medication was not available, despite some doses being present in the emergency kit. Staff interviews revealed confusion about the process for obtaining and administering medications from the emergency kit and inconsistent practices regarding physician notification when medications were unavailable.