Failure to Provide Timely Pharmacy Medication Delivery
Penalty
Summary
The facility failed to ensure that medications were available from the pharmacy for administration to a resident recently admitted with multiple complex medical conditions, including chronic diastolic heart failure, hypertension, chronic kidney disease, irritable bowel syndrome, a chronic ulcer, anxiety disorder, and an overactive bladder. The resident had care plans in place addressing risks related to diuretic therapy and ileostomy, with interventions specifying that medications should be administered as ordered. Despite an active physician order for Lomotil to manage diarrhea, the medication was not available in the medication cart when requested by the resident, who reported ongoing diarrhea and had previously asked for the medication without receiving it. Staff interviews confirmed that the Lomotil was not in stock, and the DON stated that the process for obtaining necessary medications involved drop shipping from the pharmacy, which typically took four hours. However, the medication had not arrived, and the DON acknowledged there was no facility policy specifying the timeframe for pharmacy deliveries. The lack of timely access to the ordered medication resulted in the resident not receiving needed treatment for her symptoms, as confirmed by both staff and resident interviews.