Failure to Provide Timely Pharmaceutical Services for Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition and administration of a physician-ordered medication, Ingrezza 80 mg, prescribed for tardive dyskinesia. The resident, a 68-year-old female with multiple diagnoses including pneumonia, acute respiratory failure, anxiety disorder, and schizoaffective disorder, was dependent, non-verbal, and received medications via a feeding tube. Despite a physician's order for Ingrezza with a specified start date, the medication was not administered as scheduled on several occasions because it was not available in the facility. The delay in medication administration was due to a series of procedural lapses: the DON initially placed a verbal order with the pharmacy, but the pharmacy required a signed order before filling the prescription. The signed order was not sent until several days later, and upon receipt, the pharmacy reported the medication was not in stock and had to be ordered from the manufacturer. The DON was unaware of the stock issue until after the order was submitted, and the resident did not receive the medication as prescribed. Interviews with the family, pharmacy staff, and physician confirmed the medication was not provided as ordered, and there were no alternative medications suitable for administration via feeding tube.