Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Procedures
Penalty
Summary
The facility failed to develop and implement effective pharmacy procedures to ensure that medications were timely and accurately received, dispensed, and administered to meet the needs of all seven residents reviewed for admission medication reconciliation. The pharmacy delivery schedule required that medications ordered before 10:00 AM would be delivered in the evening, and those ordered after 10:00 AM but before 7:30 PM would be delivered overnight. If medications were needed before the next scheduled delivery and the cutoff time was missed, staff were expected to request STAT delivery and utilize emergency access systems such as Omnicell. However, there was no documentation that staff followed these procedures, resulting in multiple missed doses of critical medications for several residents. Residents admitted with time-sensitive and high-risk medication needs, such as anticoagulants, antibiotics, cardiac medications, and antipsychotics, experienced significant omissions. For example, one resident with a history of blood clots did not receive scheduled doses of rivaroxaban, despite the medication being available in the Omnicell system. Another resident with a C. difficile infection missed 12 out of 25 scheduled vancomycin doses due to failures in transcribing a formulary interchange and lack of staff follow-through. Additional residents failed to receive IV antibiotics, anticonvulsants, and other essential medications due to similar lapses in order entry, pharmacy communication, and emergency medication access. Interviews with staff revealed a lack of training and awareness regarding pharmacy ordering deadlines, STAT medication requests, and the use of emergency medication systems. Some nurses were unaware of the need to fax certain medication orders or the existence of pharmacy order cutoff times. The Director of Nursing confirmed that several staff members did not have access to the Omnicell system, further contributing to the delays and omissions. These systemic failures in medication management and staff competency led to repeated missed doses and inadequate medication administration for all residents reviewed.