Failure to Administer Physician-Ordered Medication Due to Pharmacy and Staff Oversight
Penalty
Summary
Facility staff failed to administer gabapentin as ordered by the physician for a resident with multiple complex diagnoses, including traumatic wounds, pneumothorax, paraplegia, vertebra fractures, neurogenic bladder/bowel, spinal stenosis, and emphysema. The resident, who was cognitively intact, reported that several doses of gabapentin were missed over several days, and the clinical record confirmed that eleven scheduled doses were not given between 10/17/25 and 10/21/25. Documentation indicated that the medication was placed on hold due to pharmacy delivery issues, and staff interviews revealed delays in obtaining the required prescription and problems with fax communication to the pharmacy after new equipment was installed. The facility's protocol for omitted medications required staff to check the back-up supply (Omnicell), contact the provider for alternatives if the medication was unavailable, and notify the pharmacy regarding the medication's expected arrival. Despite gabapentin being available in the back-up supply, nurses did not access it, resulting in the missed doses. The deficiency was confirmed through resident and staff interviews, clinical record review, and facility policy documentation.