Failure to Provide Timely Ordered Medications Due to Access and Delivery Issues
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered as prescribed for a resident admitted with a diagnosis of alcoholic cirrhosis. Upon admission, the resident had physician orders for gabapentin and sucralfate to be administered at specific times, including a 9:00 PM dose on the day of admission. Review of the Medication Administration Record (MAR) showed that the 9:00 PM doses of both medications were not administered, and the MAR entry indicated 'Other / See Progress Notes,' but there was no documentation in the progress notes explaining the missed doses. Further investigation revealed that the medications were not delivered to the facility until the following morning, as confirmed by the pharmacy delivery manifest. Interviews with staff indicated that while the facility had an automated medication management system containing gabapentin, many agency nurses did not have access to it, and no medication was pulled from the system for this resident. The DON confirmed that most medications for the resident were not due until the next day, but the missed 9:00 PM dose was not addressed or documented appropriately.