Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of multiple residents, resulting in missed, delayed, or omitted medication doses. For several residents, medications were not administered as ordered due to various reasons, including the facility's internet being down, medications being unavailable, and untimely administration by nursing staff. Facility policies required medications to be administered in a safe and timely manner, within one hour of the prescribed time, and for medication errors to be documented and reported. However, these policies were not consistently followed. One resident with multiple sclerosis, convulsions, major depressive disorder, and vitamin D deficiency did not receive scheduled medications at two different times because the facility's internet was down, and staff did not utilize available contingency plans such as printed MARs or alternative internet access. Another resident with rhabdomyolysis and traumatic ischemia of muscle also missed a scheduled dose for the same reason. Interviews with the DON and ADON confirmed that these omissions were considered medication errors and that staff were not fully aware of or did not implement alternative procedures during the internet outage. Additional deficiencies included a resident with metabolic encephalopathy, sepsis, diabetes, epilepsy, and other conditions who missed multiple doses of critical medications over several days due to drug unavailability, despite the facility having a contingency supply. Another resident with end stage renal disease and epilepsy did not receive several medications after returning from a hospital stay because orders were not promptly renewed and medications were not available for an extended period. Furthermore, a resident reported regularly receiving medications late, and review of MARs and staff interviews confirmed that morning medications were administered well outside the required time frame, constituting medication errors. These events demonstrate failures in medication acquisition, timely administration, and adherence to facility policy.