Failure to Provide Timely and Accurate Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that met the needs of several residents by not acquiring medications from the pharmacy in a timely manner, administering medications as ordered, and properly documenting medication administration. In multiple instances, nursing staff used medications prescribed for one resident to treat another, due to missing or unavailable supplies. For example, a registered nurse was observed using silver sulfadiazine cream labeled for a different resident on a patient with a pressure ulcer, stating she could not locate the correct cream. Another resident received wound care with a tub of cream that had no identifying label, and the nurse admitted she did not know to whom it belonged but used it because the resident's own supply was missing. Residents also reported missed treatments and delays in wound care due to running out of prescription creams and wound supplies. One resident stated that wound care was skipped for several days because the necessary medication was unavailable, and staff confirmed that they sometimes borrowed supplies from other residents or postponed care until the next shift. Staff interviews revealed that this practice of borrowing or delaying treatments occurred when supplies were not available, and the Director of Nursing acknowledged that residents should not run out of medications if staff communicated the need for reordering. Additionally, there were failures in medication administration and documentation. One resident did not receive their scheduled morning medications because the nurse forgot to administer them and only realized the omission later. After consulting with a nurse practitioner, the nurse attempted to administer the medications, but the resident refused most of them due to the delay. The nurse then incorrectly documented the refusal in the electronic health record and was unable to correct the error. The nurse also failed to notify the physician or physician assistant about the missed doses, as required by facility policy. These deficiencies were observed and confirmed through interviews, record reviews, and direct observation.