Failure to Ensure Timely Availability of Ordered Medications for New Admissions
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services to meet the needs of residents, specifically by not ensuring timely availability and administration of ordered medications for three residents. Facility policy required routine and timely pharmacy service, including 24/7 emergency access and use of primary, backup, or emergency medication supplies so that new medication orders would be available by the next routine delivery unless otherwise requested. Despite this, multiple ordered medications, including critical antiseizure drugs, were not available and were not administered as ordered for several newly admitted residents. One resident with diagnoses including epilepsy, type 2 diabetes mellitus, and sepsis was admitted from the hospital with multiple medication orders, including Carbamazepine and Phenobarbital for epilepsy. Review of the MAR and nursing notes showed that the resident’s evening dose of Carbamazepine and Doxycycline on the day of admission, and the following morning doses of Carbamazepine, Doxycycline, Finasteride, Metoprolol, Phenobarbital, Pregabalin, and Rosuvastatin were not given because the medications were not available. The clinical record confirmed that the resident missed one dose of Carbamazepine on the first day and two doses of antiseizure medications (Carbamazepine and Phenobarbital) on the next day. Later that day, the resident was found on the floor next to the bed, unresponsive with seizure-like activity and a moderate amount of blood on the forehead; the episode lasted approximately five minutes, after which the resident was lethargic and postictal. EMS transported the resident to the hospital, where evaluation documented treatment for seizure activity and a head laceration, and imaging revealed a mildly displaced fracture of the right radial head. The emergency room physician documented that the resident reported having lifelong seizures that were very well controlled with medication, with the last seizure occurring in the 1990s, and that the facility did not have the seizure medications in stock and was unable to administer them. A second resident, with diagnoses including type 2 diabetes mellitus, epilepsy, and sepsis, was admitted from the hospital with orders for multiple medications, including Divalproex Sodium and Levetiracetam for seizures, Glipizide for diabetes, Memantine, Movantik, and Unisom. Review of the MAR showed that several scheduled doses over multiple days were either left blank or coded as not given, with corresponding nursing notes stating that the medications were not available. Missed or unavailable doses included evening doses of Divalproex and Unisom on the day of admission, and on subsequent days, morning and later doses of Divalproex, Glipizide, Levetiracetam, Movantik, Memantine, and Unisom. A third resident, with epilepsy and major depressive disorder, was admitted from the hospital with orders for Imipramine, Lamotrigine, and Topiramate. The MAR and nursing notes showed that several initial doses of these medications on the first and second days after admission were not administered because the medications were not available. During interviews, facility leadership stated that the contracted pharmacy delivers twice daily and that a local pharmacy can be used as backup for emergent medications, and acknowledged uncertainty about where the communication breakdown occurred that led to the unavailability of medications.
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