Failure to Administer Medications per Physician Orders Due to Pharmacy Delivery Issues
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents who were prescribed Repatha (Evolocumab) for hyperlipidemia and hypertriglyceridemia. For one resident with diagnoses including type II diabetes mellitus with foot ulcer and chronic heart failure, physician orders specified Repatha injections every three weeks, but review of the Medication Administration Records (MAR) and pharmacy delivery slips showed that only five of thirteen ordered doses were administered between March and November. The Director of Nursing (DON) confirmed that the medication was not consistently delivered by the pharmacy as ordered, and when the medication was unavailable, staff would sometimes discontinue and rewrite orders to prompt delivery. Only eight doses were documented as delivered by the pharmacy during this period. Another resident with multiple diagnoses, including respiratory failure, diabetes with polyneuropathy, and chronic heart failure, was ordered Repatha injections every two weeks. Review of records indicated that only four of eleven ordered doses were administered, with only five doses documented as delivered by the pharmacy. The DON confirmed that the medication was not administered as ordered due to delivery issues, and similar to the first case, staff would discontinue and rewrite orders to facilitate delivery. Facility policy required medications to be administered safely, timely, and as prescribed, but this was not followed in these cases.