Failure to Provide Medications as Ordered Due to Unavailability and Delayed Pharmacy Delivery
Penalty
Summary
Facility staff failed to provide medications as ordered for four residents, resulting in missed doses and lack of timely administration. For one resident, Panoxyl (benzoyl peroxide) was ordered to be applied daily for acne, but the medication was only administered a fraction of the required times over a period of weeks. Documentation showed repeated notes of the medication being pending, pharmacy being notified, and awaiting delivery, with the Omnicell system lacking the medication. The facility's policy required staff to notify the physician and seek alternative orders if a medication was unavailable, but there was no evidence that this was consistently done. Another resident did not receive Clotrimazole, Aripiprazole, and Fluticasone-Salmeterol as ordered, with the eMAR indicating the medications were not available and pending delivery. The Omnicell system did not have these medications in stock, and there was no documentation that the physician was notified about the unavailability. Similarly, a third resident did not receive multiple medications, including Colesevelam, Lyrica, Senokot, and Sevelamer Carbonate, upon admission, as the medications had not yet been received from the pharmacy. Staff interviews confirmed that while orders are transmitted to the pharmacy and stat delivery is possible, the process was not always effective in ensuring timely medication availability. A fourth resident was not administered Gabapentin as ordered for several scheduled doses, with progress notes indicating the medication was on order from the pharmacy. Although lower-dose Gabapentin was available in the Omnicell, staff did not use it due to the need for a new prescription for the different dosage. Interviews with staff and the facility pharmacist confirmed that procedures for obtaining medications from the pharmacy and using available stock were not always followed, and there was a lack of documentation of physician notification when medications were unavailable.