Failure to Provide Timely Pharmaceutical Services for Controlled Medication
Penalty
Summary
A deficiency occurred when a resident with a history of major depressive disorder, panic disorder, generalized anxiety disorder, and bipolar disorder was not administered her prescribed Clonazepam 0.5 mg for three consecutive days. The medication was not available from the pharmacy during this period, and the facility failed to obtain it in a timely manner. The resident's medication administration record and narcotic count sheet confirmed the gap in medication availability, and interviews with staff revealed uncertainty about the process for reordering controlled substances and a lack of communication with the Director of Nursing (DON) and the resident's physician or nurse practitioner. The facility's policies required that medications, especially controlled substances, be reordered when a five-day supply remained and that the DON be notified to facilitate reordering. However, the responsible nurse did not notify the DON or the pharmacy promptly, and the DON was unaware of the medication lapse until after the fact. The nurse documented the medication as 'on order' in the resident's progress notes but did not escalate the issue or report the missed doses as a medication error, as required by facility policy. Additionally, there was no documentation of staff notifying the resident's physician or nurse practitioner about the missed doses. Interviews with staff indicated confusion regarding who was responsible for reordering narcotic medications and a lack of adherence to the facility's established procedures. The DON confirmed that she was the only authorized agent to call in narcotic medication orders but was not informed of the need. The resident reported that staff often claimed she refused her medication, and observation confirmed the medication was not available during the specified period. Facility records and interviews corroborated that the medication was not administered due to the facility's failure to obtain it from the pharmacy.