Failure to Provide and Document Pharmaceutical Services for Antianxiety Medication
Penalty
Summary
The facility failed to provide pharmaceutical services as required for one resident with a history of generalized anxiety disorder. Specifically, the resident had a physician's order for clonazepam, an antianxiety medication, to be administered at bedtime. Review of the medication administration record (MAR) showed that the medication was not available and not administered from 6/22 to 6/28, with the MAR marked as absent or left blank for those dates. There was no documented evidence that the physician, pharmacy, or the resident's responsible party were notified about the unavailability of the medication, despite a nurse stating that such notifications were made but not documented in the medical record. Additionally, the facility failed to maintain required narcotic count sheets for the resident's clonazepam for May and June, as these records were missing from the medical record. Interviews with staff revealed that a new supply of the medication was not reordered as needed, and the DON confirmed the absence of the narcotic count sheets and was unaware of the medication's unavailability. These failures were identified through observation, interviews, and review of facility policies and records.