Failure to Ensure Timely Initiation and Continuation of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to timely initiation and continuation of ordered medications. Facility policy required that medications be obtained and administered in a timely manner, with new orders to be started within 24 hours unless otherwise specified, and that nurses reorder medications when six or fewer doses remained. Despite this, the process for entering and obtaining medications from the pharmacy did not function as intended, resulting in missed doses for two residents. For one resident admitted with dental pain and infection, a dentist evaluated the resident and prescribed Augmentin to be given twice daily for 10 days, with the medication to be delivered by the pharmacy. The LPN on duty documented faxing the new antibiotic order to the pharmacy on the day of the dental visit. The following morning, when the resident complained of significant jaw pain and stated they had not received the antibiotic, the LPN confirmed there was no antibiotic listed in the resident’s electronic orders and contacted the pharmacy. The pharmacy reported the medication was at the facility, but the order had not yet been entered into the medical record, and the resident had not received the first dose the day it was ordered. For another resident with a primary diagnosis of Type 2 Diabetes Mellitus, the Medication Administration Record showed an ongoing order for Ozempic 2 mg to be injected once weekly at 7:00 AM. On the scheduled administration date, the LPN was unable to locate the Ozempic on the medication cart or in the medication storage room and confirmed that the injection due that morning could not be given. The LPN later verified that the last person who administered the weekly Ozempic dose had not reordered the medication when the previous dose was given, contrary to facility practice for once-weekly medications. The DON confirmed that the last nurse to administer the Ozempic was responsible for reordering it and that this had not occurred, resulting in a missed scheduled dose.
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