Failure to Ensure Timely Medication Administration Due to Inadequate Reordering Practices
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents, resulting in significant medication errors. One resident did not receive five doses of a physician-ordered anti-seizure medication, Zonisamide, due to the medication being on order from the pharmacy and not available for administration. This resident subsequently experienced increased seizure activity, including seizures lasting longer than five minutes, which led to a transfer to the emergency department. Documentation and interviews revealed inconsistent practices among staff regarding when to reorder medications, with some staff waiting until the last dose was administered and others reordering with several doses remaining. The pharmacy was not notified in a timely manner, and the facility's policy required medications to be reordered in advance, with a three-day minimum supply remaining. Another resident did not receive a physician-ordered blood clot prevention medication, Coumadin, for seven days. The missed doses were attributed to a change in the resident's lab schedule, which affected the pharmacy's ability to adjust and supply the medication. The pharmacy was not notified of the updated schedule, resulting in the medication not being reordered or administered during this period. The resident's electronic medical record confirmed the absence of Coumadin administration for the specified days. Interviews with nursing staff and the pharmacy director highlighted a lack of consistent understanding and adherence to medication reordering procedures. Staff reported varying practices for reordering medications, and the pharmacy director noted that medication requests sent by fax on weekends or holidays were not checked, despite the availability of a phone number for urgent orders. The facility's policy and medication reorder sheets instructed staff to reorder medications in advance to prevent missed doses, but these procedures were not consistently followed, leading to the deficiencies identified.