Failure to Provide Timely and Ordered Pharmaceutical Services
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident as ordered by the physician, specifically not administering prescribed IV antibiotics through a PICC line and ordered Lovenox injections following surgery for a right hip fracture. The resident, who had a complex medical history including sepsis, dementia, Alzheimer's disease, and a recent hip fracture, was dependent on staff for activities of daily living and required special treatments such as IV antibiotics and anticoagulant therapy. Upon admission and re-admission, there were multiple documented instances where the facility did not have the necessary medications available in a timely manner, resulting in missed doses of critical medications such as Cefazolin, Ertapenem, and Lovenox. Nursing notes and interviews revealed that the resident's PICC line was pulled out and later replaced, but there were delays in obtaining and administering IV antibiotics due to pharmacy delivery issues and uncertainty about which infusion company to contact for PICC line replacement. Staff documented that medications were not administered because they were awaiting delivery from the pharmacy, and there was confusion regarding the process for obtaining stat medications or using the facility's emergency kit. Additionally, the resident frequently refused injections, and while staff attempted to notify the physician and obtain alternative orders, there were lapses in communication and documentation, including not notifying the responsible party of changes in treatment. Interviews with nursing staff, the DON, and administrative personnel indicated a lack of formalized tracking for medication delivery timeliness and inconsistent procedures for handling medication refusals, missed doses, and PICC line complications. The facility's own policies required timely administration of medications and physician notification when doses were missed, but these were not consistently followed. The failure to ensure timely availability and administration of prescribed medications, as well as inadequate communication and follow-up, led to the resident not receiving necessary treatments as ordered.