Failure to Timely Acquire and Administer Physician-Ordered Medications Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was admitted following knee revision surgery with a polymicrobial infection and a chronic open wound. Upon admission, the resident had physician orders for an intravenous antibiotic (Daptomycin-Sodium Chloride), a central nervous system stimulant (Adderall), and a therapeutic nutrition powder (Juven) for wound healing. However, the facility did not acquire and administer these medications in a timely manner, resulting in the resident missing one dose of the antibiotic, six doses of Adderall, and seven doses of Juven over several days after admission. Record reviews showed that the first dose of the antibiotic was not given until the day after admission, Adderall was not administered until several days later, and multiple doses of Juven were missed. Interviews with the resident and staff revealed confusion and lack of clarity regarding the delay in medication delivery. The resident reported not receiving some medications for a few days and was told the facility was trying to obtain them from the pharmacy. Staff interviews indicated that the pharmacy did not deliver all medications as expected, and there was uncertainty about the steps taken to resolve the issue. The facility's policy required that upon admission, the charge nurse and DON or designee review and reconcile physician orders for accuracy in the electronic medical record. However, interviews with staff, including the ADON and RDCS, indicated that the process for ensuring timely medication acquisition and administration was not effectively followed, and there was no clear documentation or explanation for the missed doses. The failure to provide the ordered medications as prescribed was confirmed through both record review and staff interviews.