Failure to Provide Timely Medications for Respite Care Resident
Penalty
Summary
The facility failed to have effective systems in place to obtain and provide medications for a newly admitted respite care resident, resulting in multiple missed doses of eleven prescribed medications. The resident, who had complex medical needs including end stage renal disease requiring dialysis, glaucoma, GERD, and dementia, was admitted for a short-term stay. Despite having clear physician orders for a range of medications, including eye drops, oral medications, and a phosphate binder, the facility did not ensure these medications were available and administered as ordered. Nursing notes and interviews revealed that the resident's medications were not received or administered for several days after admission. Staff reported confusion regarding the process for obtaining medications for respite care residents, particularly those enrolled in a managed care program. The contracted pharmacy did not receive requests to fill the resident's medications until several days after admission, and the managed care pharmacy did not provide medications for respite stays. As a result, the resident missed multiple doses of critical medications, as documented in the Medication Administration Record (MAR), with many doses left blank, held, or otherwise not given. Interviews with nursing staff, the DON, and pharmacy representatives confirmed a lack of clarity and established procedures for obtaining and administering medications to respite care residents. The facility's staff gave inconsistent answers about whether medications should be brought from home or obtained from the contracted pharmacy, and there was no evidence that a consistent or effective process was followed. The resident's vital signs remained stable during the stay, and no harm was identified by the nurse practitioner, but the deficiency was due to the facility's failure to ensure medications were available and administered as ordered.