Failure to Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to obtain and administer a prescribed medication, pregabalin, to a resident following their return from a hospital admission. The resident, who had diagnoses including chronic kidney disease, convulsions, morbid obesity, type II diabetes mellitus, anxiety disorder, major depressive disorder, and lymphedema, had a care plan that included pain management with medications as ordered by a physician. Upon readmission, a physician ordered pregabalin 75 mg twice daily for neuropathy, but the medication was not administered from the evening of admission through several days, as documented in the medication administration record and progress notes. The lack of administration was due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The pharmacy required a new prescription for the changed dosage, but did not receive it despite notifications to the facility's nurse practitioner and follow-up attempts. The resident did not receive pregabalin for multiple days, except for a brief period when an on-call nurse practitioner provided a three-day supply. The resident was unaware of the reason for the interruption in her pain medication, and facility leadership confirmed the medication was not available or administered as ordered during the specified periods.