Failure to Administer Prescribed Medication Due to Pharmacy and Communication Lapses
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with quadriplegia and migraines. The resident did not receive his prescribed Qulipta medication on three consecutive days, as documented in the Medication Administration Records (MARs) for those dates. Interviews revealed that nursing staff were aware the medication was unavailable due to a delay in pharmacy delivery, but did not contact the pharmacy to expedite delivery or notify the physician about the missed doses. The resident reported to surveyors that he was informed by nurses that his medication was out of stock. Further interviews with nursing staff indicated a lack of clarity regarding responsibility for contacting the pharmacy and notifying the physician when medications were not available. The Director of Nursing (DON) and Administrator both stated that nurses were expected to ensure medications were administered as ordered and to notify appropriate personnel if medications were missed, but neither was made aware of the missed doses. The facility's policy required medications to be administered as prescribed and in accordance with physician orders, which was not followed in this instance.