Failure to Provide Timely and Complete Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely and appropriate pharmaceutical services to meet the needs of two residents. For one resident, multiple medications, including maintenance inhalers, blood pressure medications, anticoagulants, and pain relievers, were administered outside the facility's policy of a 60-minute window from the scheduled administration time. Documentation showed that morning medications were often given two to three hours late over several consecutive days, and evening doses were sometimes given too early or not documented as administered at all. There was also no evidence that required blood pressure and heart rate checks were performed prior to administering certain cardiac medications, as ordered. Additionally, the same resident's medication administration record lacked documentation for several scheduled doses, with no indication that the resident refused or was unavailable for medication administration. The DON confirmed that the resident was permitted to self-administer medications, but the times recorded reflected when staff provided the medications, not when they were actually taken. For another resident, who was re-admitted from the hospital with a PICC line and orders to continue IV and oral antibiotics, the facility failed to obtain and administer these medications in a timely manner. The IV antibiotic was not ordered or given until three days after admission, and the oral antibiotic was not ordered or administered until six days after admission. The delay was attributed to missing hospital discharge documentation and lack of transcription of the orders, resulting in missed doses as noted by the attending physician. Laboratory results also indicated subtherapeutic levels of the IV antibiotic during this period.