Failure to Ensure Timely Administration and Availability of Prescribed Chemotherapy Medication
Penalty
Summary
The facility failed to ensure that a resident with multiple myeloma received their prescribed medication, lenalidomide, according to the physician's orders. The medication was to be administered in a 28-day cycle, with 21 days on and 7 days off, but there were multiple documented instances where the medication was not available or not administered as ordered. Review of the Medication Administration Records (MAR) over several months revealed repeated gaps in administration, with cycles starting late, not restarting on time, or being missed entirely. There was no physician order to stop the medication at any point, and the MARs did not reflect any authorized changes to the regimen. Interviews with facility staff and the infection preventionist (IP) confirmed that the medication was only available through a specialty pharmacy, which required the facility to order the medication for each cycle individually. The IP acknowledged that the medication order would fall off the electronic system after a few months and had to be manually re-entered, which contributed to the missed doses. The pharmacy representative corroborated that there were months when no medication was ordered or delivered, and staff interviews confirmed that there were times when the medication was not available for administration. There was also a lack of documentation or receipts to show that the medication was obtained from any other source during the periods when the pharmacy did not deliver it. Additionally, there was no evidence that the resident's oncologist was notified of the medication errors, despite the ongoing issues with medication availability and administration. Staff interviews indicated inconsistent practices regarding the storage and tracking of the medication, with reports of extra medication being kept in the medication cart at times, but no clear process for ensuring continuous supply. The facility's failure to maintain a consistent supply and administration of the prescribed medication led to significant lapses in care for the resident.