Failure to Provide Timely Pharmaceutical Services Due to Lapses in Communication and Medication Management
Penalty
Summary
Pharmaceutical services failed to meet the needs of a resident who was prescribed eszopiclone for insomnia. The resident, who had diagnoses including bipolar disorder, Lupus anticoagulation syndrome, and insomnia, did not receive six consecutive doses of the medication. Documentation showed the medication was not administered over several days, with some days marked as unavailable and others lacking any documentation. The facility's medication administration policy required staff to check overflow supplies, emergency boxes, and to notify the medical provider and pharmacy if a medication was unavailable, but these steps were not consistently followed. The nurse did not contact the medical provider or pharmacy to obtain the medication or an alternative, and there was no documentation in the nurse progress notes regarding the missed doses or unavailability of the medication. The delay in administration was due to the need for prior insurance authorization, which was not obtained until after multiple missed doses. The resident reported the issue through a grievance, and interviews revealed that staff, including the LPN and DON, were aware of the medication's unavailability but did not take all required actions to resolve the issue or communicate with the medical provider in a timely manner. The pharmacy also indicated that prior authorization was necessary, but there was confusion about who was responsible for obtaining it and notifying the facility. The physician and nurse practitioner were not promptly informed of the missed doses, which delayed the possibility of ordering an alternative medication.