Failure to Ensure Timely Acquisition and Administration of Critical Medications
Penalty
Summary
The facility failed to provide uninterrupted pharmaceutical services for three residents, resulting in missed doses of critical medications. One resident with HIV did not receive the prescribed antiretroviral medication, Biktarvy, for several days due to a lapse in obtaining a new prescription and insurance approval. The medication was initially supplied by a hospital pharmacy, but when the supply was depleted, the facility pharmacy could not provide a refill without a new prescription and insurance authorization. Multiple staff members, including nurses, the Medical Director, and pharmacy personnel, were aware of the issue, but there was a lack of coordinated action to secure the medication in a timely manner. Documentation showed that the resident missed multiple doses, and there was confusion and miscommunication among staff regarding responsibility for obtaining the medication and ensuring its availability on the medication cart. Another resident with diabetes missed a scheduled dose of Ozempic because the medication was not available at the time of administration. The nurse reported the absence of the medication and contacted the pharmacy, but the medication was not delivered in time for the scheduled dose. Subsequent attempts to locate the medication for the next scheduled dose were unsuccessful, and the pharmacy indicated that a refill could not be processed because the facility should have had a dose available from a previous delivery. Despite documentation indicating delivery of the medication, there was no evidence that the resident received the dose, and staff interviews confirmed the medication was not administered as ordered. A third resident with allergic rhinitis did not receive the prescribed Fluticasone nasal spray as ordered. Although the medication administration record indicated that the medication was given, interviews with staff and the resident revealed that the medication was not available on the medication cart and had not been administered. Staff reported inadvertently documenting administration when the medication was not present, and pharmacy records showed that the facility had requested the medication before it was eligible for refill. The medication was eventually located in another unit's storage, but the resident had gone without the prescribed treatment for several days.