Failure to Provide Timely and Authorized Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three residents. In the first instance, a resident with chronic pain and multiple comorbidities, including peripheral vascular disease and hemiplegia, did not receive his scheduled dose of Morphine at the prescribed time. The medication, ordered to be administered twice daily at 9:00 am and 5:00 pm, was instead given at 7:57 pm by an LVN who was unaware of the scheduled time and cited being busy and unfamiliar with the number of scheduled narcotics. The LVN acknowledged not following facility policy, which requires medications to be administered within a one-hour window of the scheduled time. A second resident, who had severe cognitive impairment and multiple diagnoses including vascular dementia and hemiplegia, also did not receive her scheduled dose of Tramadol at the prescribed time. The medication, ordered for administration twice daily at 9:00 am and 5:00 pm, was given at 8:00 pm. The responsible LVN was not available for interview, but the DON confirmed the medication was administered late due to staffing issues, specifically the absence of a medication aide, and that the LVN was responsible for the delay. The facility policy, as stated by the DON, requires timely administration of medications within a one-hour window. In a third case, another resident with a history of heart failure, chronic kidney disease, and diabetes received Tramadol without a current physician order. The LVN administered the medication after the resident requested it, mistakenly believing the order was still active following a recent hospital stay. The LVN did not review the resident's chart prior to administration and did not contact the physician to confirm or obtain a new order. The DON confirmed that the medication was given without an order and that this was not in accordance with facility policy, which prohibits administering medications without a valid physician order.