Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring timely receipt and administration of prescribed medications. One resident, with multiple diagnoses including hemiplegia, GERD, anxiety, depression, COPD, and others, had a physician's order for Debrox Otic Solution for ear wax removal. Documentation showed that over a four-day period, the medication was not available and was not administered as ordered. Progress notes repeatedly indicated the facility was awaiting the medication from the pharmacy, and there was no evidence that the physician was notified about the unavailability or missed doses. Interviews with nursing staff and the DON confirmed the medication was not received or administered, and the physician was not informed. Another resident, with diagnoses including lung cancer, COPD, diabetes, brain cancer, chronic pain, and heart failure, had an order for Tramadol for pain management. The medication was ordered from the pharmacy several days after the physician's order and was not delivered for seven days. The resident reported being in pain and not receiving the medication, and staff interviews confirmed ongoing issues with timely receipt of both prescription and OTC medications from the pharmacy. Facility staff described frequent delays and the need to purchase OTC medications from outside sources due to inconsistent pharmacy deliveries. The facility's policy required medications to be administered according to orders and within required time frames, which was not followed in these cases.