Failure to Ensure Timely Acquisition and Administration of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one of twelve sampled residents. Facility policy required medications to be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. For a resident admitted with diagnoses including bipolar disorder and major depressive disorder, multiple physician orders for medications such as Lamotrigine, Olanzapine, Clonazepam, Lithium, Simethicone, and Cefepime were not followed as prescribed. Medication Administration Records (MAR) showed blank entries or notes indicating medications were not available and were awaiting pharmacy delivery on several occasions. There were also instances of delayed administration, such as a four-hour delay in administering Cefepime. The resident involved was cognitively intact, as indicated by a BIMS score of 13, and had several mental health and medical conditions requiring consistent medication management. Interviews and record reviews confirmed that the facility did not ensure medications were obtained and administered as ordered, due to misunderstandings between nursing staff and the pharmacy regarding medication availability. This resulted in missed or delayed doses for multiple prescribed medications, in violation of facility policy and state regulations.