Failure to Administer Ordered Medications Timely for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were administered timely according to physician orders for two residents, resulting in delays in care. One resident, who had multiple serious diagnoses including MRSA infection, sepsis, and peripheral vascular disease, was admitted with orders for intravenous antibiotics. Despite the physician's order for Ceftaroline Fosamil to be administered every eight hours, the resident did not receive any doses during his stay because the medication was not available. The pharmacy required payment authorization due to the high cost, and the facility did not provide this authorization until several days after the order was placed. During this period, the resident's condition worsened, with increased pain and significant discoloration and necrosis of his toes, ultimately leading to a hospital transfer and subsequent above-the-knee amputation. Another resident, admitted with a seizure disorder, diabetes, and hypertension, also experienced a delay in receiving a critical medication. The resident was ordered to receive Lacosamide for seizure control twice daily, but missed a total of ten scheduled doses over several days. The delay was due to the lack of a signed prescription, which was not obtained promptly from the physician. Nursing staff documented that the medication was on order and that the physician was aware, but the prescription was not signed and accepted by the pharmacy until several days after admission. During this time, the resident did not receive the ordered seizure medication. In both cases, the facility did not follow its own policy requiring medications to be administered in accordance with physician orders. The delays were attributed to administrative and communication failures between the facility, pharmacy, and physician, resulting in missed doses of essential medications for both residents. The documentation shows that staff were aware of the missed doses and the reasons for the delays, but did not ensure timely resolution to provide the necessary care as ordered.