Failure to Maintain Timely Supply of Controlled Substance Medication
Penalty
Summary
A deficiency occurred when the facility failed to maintain a timely supply of a Schedule IV controlled substance, Lunesta (eszopiclone), for a resident diagnosed with schizoaffective disorder, major depressive disorder with psychotic symptoms, generalized anxiety disorder, auditory hallucinations, and insomnia. The resident had a physician's order for Lunesta 2 mg to be administered at bedtime, but documentation showed that the medication supply was depleted and not replenished in a timely manner. The facility's records indicated that after the last dose was sent with the resident on a home visit, there were no further deliveries of Lunesta until a new prescription for an increased dose was received and filled several days later. During the period when Lunesta was unavailable, administration and nursing notes documented that staff were waiting on a signed prescription from the psychiatric provider, which is required for controlled substances. Multiple attempts were made by nursing staff to contact the psychiatric provider for the necessary prescription, but there was a delay in response. The medical director was notified of the situation, and an alternative medication, melatonin, was ordered to be given as needed for insomnia until the Lunesta prescription could be filled. The resident was aware of the missed doses and expressed concern about the interruption in receiving the prescribed medication, stating that the alternative medication did not work as well as Lunesta. Staff interviews confirmed that the delay was due to the psychiatric provider's failure to provide a signed prescription, despite repeated requests from the facility. The documentation shows that the resident went several days without the prescribed controlled substance due to this delay.