Failure to Provide Timely Pharmaceutical Services for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate receiving, dispensing, and administration of medication for a resident who reported left eye redness. The resident complained of eye redness and was assessed by a physician, who ordered tobramycin ophthalmic solution to be administered four times daily for five days. However, the medication was not received or administered as ordered due to the eye drops being lost by an overnight nurse and subsequent issues with insurance coverage for a reorder. Documentation in the electronic medication administration record (eMAR) and nursing progress notes confirmed that the medication was not given from the time it was ordered through the following eleven days. During this period, the resident's condition worsened, leading her to request emergency room care, where she received the prescribed eye drops. Interviews with nursing staff, the unit manager, and the administrator confirmed the delay in obtaining the medication and the lack of administration as ordered. The administrator expressed dissatisfaction with the pharmacy's handling of the situation, and the resident ultimately required external medical intervention due to the facility's failure to provide timely pharmaceutical services.