Delayed Medication Administration for New Admissions Due to Pharmacy Issues
Penalty
Summary
The facility failed to ensure that newly admitted residents received their prescribed medications in a timely manner due to delays in obtaining medications from the pharmacy. Multiple residents experienced missed doses of critical medications for several days after admission. For example, one resident with diagnoses including pleural effusion, chronic kidney disease, cirrhosis, atrial fibrillation, diabetes, and C. difficile did not receive Vancomycin, Sucralfate, and Gabapentin as ordered, with documentation indicating repeated notes of 'awaiting pharmacy' and no evidence that the physician or nurse practitioner was notified of the missed doses. Another resident admitted with conditions such as weakness, COPD, cirrhosis, hepatitis C, diabetes, and congestive heart failure did not receive several ordered medications, including Clopidogrel, Lantus insulin, nicotine patch, Sertraline, Trelegy inhaler, Cefazolin, and Creon, for several days. Nursing notes repeatedly documented that medications were not delivered or were on order, and the nurse practitioner was not notified of the missing doses until several days after admission. The medication Creon was eventually placed on hold until it became available. A third resident with atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes, and chronic kidney disease did not receive lactulose for two days after admission, with nursing notes indicating the medication was 'awaiting from pharmacy.' Interviews with staff confirmed ongoing issues with timely pharmacy delivery, especially for new admissions, and that the facility's medication dispensing system did not always have the required medications on hand. There was also a lack of documentation that the physician or nurse practitioner was notified when medications were missed, contrary to facility policy.