Failure to Provide Timely Pharmaceutical Services Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident. The resident, who had diagnoses including left total knee arthroplasty, osteoarthritis, cellulitis, and diabetes, was admitted with intact cognition and was responsible for their own healthcare decisions. Physician orders were in place for D-Mannose, nateglinide, and pregabalin, with specific dosages and administration times. However, a review of the Medication Administration Audit Report revealed multiple instances where these medications were not administered as ordered due to unavailability. Specifically, D-Mannose, nateglinide, and pregabalin were missed on several occasions over a period of days, with documentation indicating the medications were not available at the facility at the required times. The facility's policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time unless otherwise specified. Despite this, the medications were not provided to the resident according to physician orders. During an interview, the Director of Nursing confirmed that the pharmacy is expected to deliver medications when ordered and that staff should contact the pharmacy with a stat order if medications are not delivered, indicating that the established procedures for obtaining medications were not followed in these instances.