Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide routine and emergency pharmaceutical services to meet the needs of a resident, as required by policy and regulation. Specifically, a resident with multiple chronic conditions, including chronic kidney disease, diabetes, heart failure, and atrial fibrillation, did not receive two ordered medications—apixaban and Spiriva—at the scheduled time. Observations during medication pass revealed that both medications were missing from the medication cart, and staff were unable to locate apixaban in the emergency stock. After contacting the nurse practitioner, orders were received to hold the medications due to their unavailability. The resident eventually received the available medication later in the morning, but Spiriva remained unavailable. Interviews with staff and pharmacy personnel revealed that apixaban had been ordered several days prior and was only delivered the night before, while Spiriva had not been filled due to an unexplained delay and subsequent insurance denial. The pharmacy cited staffing shortages and indicated that medication turnaround should typically be 24 hours. Facility staff reported that medication reordering should occur a week in advance, and if medications are unavailable, the pharmacy and prescriber are contacted. Despite these procedures, the resident did not receive all prescribed medications as ordered, constituting a failure to ensure timely access to necessary pharmaceutical services.