Failure to Administer Ordered Hypnotic Medication Due to Pharmacy and Communication Delays
Penalty
Summary
The facility failed to ensure that medication was dispensed and administered as ordered for one resident with a diagnosis of insomnia. Upon admission, the resident had a physician's order for zolpidem 10 mg at bedtime, but review of the medication administration records (MAR) showed that the medication was not administered on several occasions, with some doses marked as 'Medication Unavailable/Pharmacy Notified' and others left blank. The facility's records indicated that the medication was not available in the automated dispensing system (Pyxis), and pharmacy deliveries were delayed, with only a partial supply delivered several days after admission and the remainder not delivered until the day of discharge. Staff interviews revealed that when medications were unavailable, the protocol was to contact the pharmacy and document the communication, but there were lapses in follow-up to obtain a new prescription when needed. The pharmacy required a new prescription to dispense the medication, and although a three-day supply was eventually provided after pharmacy contact with the provider, there was no evidence of timely follow-up for additional prescriptions. The Director of Nursing was unaware that the medication had not been available and stated that the expectation was for staff to obtain necessary prescriptions or escalate the issue for assistance. Facility policy required prompt delivery of drugs and documentation of any shortages or irregularities, but in this case, the process failed to ensure the resident received the prescribed hypnotic medication as ordered. The deficiency was identified through record review, staff and pharmacy interviews, and policy review, confirming that the facility did not meet the requirement to provide pharmaceutical services to meet the needs of each resident.