F0755

G

Failure to Ensure Timely Provision and Documentation of Controlled Medications

Carlisle, Pennsylvania Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquisition, receipt, dispensing, and administration of medications for two residents, including an antiepileptic drug for a resident with epilepsy and dementia. Facility policy required that Schedule II medications be delivered only upon receipt of a faxed or original prescription, allowed emergency use of medications from the emergency supply with pharmacist authorization, and directed that Schedule II medications be reordered when a seven-day supply remained. For Resident 1, who had orders for lacosamide 100 mg by mouth every 12 hours for seizure management, the Controlled Substance Record showed 30 tablets received on December 29, 2025, with administration beginning January 1, 2026, and the last documented dose given on January 15, 2026, at 8:00 PM. The January 2026 MAR documented lacosamide doses on January 16 and 17 as “Hold/See Nurses Note,” and medication administration notes on January 16 and 17 indicated the lacosamide was on order, on back order, and not available, with repeated calls to the pharmacy.

On January 17, nursing progress notes documented seizure activity for Resident 1. One note by an LPN at 10:40 PM described a seizure from 10:20 PM to 10:26 PM and stated that the pharmacy had earlier indicated the lacosamide would be sent, but later reported that a prescription was needed to dispense it. Another note by an RN at 11:20 PM documented a seizure lasting approximately 20–25 minutes, notification of the physician, and that the ordered lacosamide was not available, leading to an order to send the resident to the hospital for evaluation and treatment. A written statement from an LPN dated January 28, 2026, indicated that on January 16 the LPN called the pharmacy to report that the resident was out of lacosamide, that it had been ordered days prior, and that the pharmacy said it would be on the next delivery. On January 18, a nurse’s note recorded another seizure for Resident 1 lasting from approximately 7:06 AM to 7:23 AM, physician notification, review of medication concerns with the physician, a new order for Ativan 1 mg IM every 12 hours as needed for seizure activity, and a second transfer to the emergency room. The same note documented that EMS staff were informed of concerns regarding lacosamide, that a voicemail was left for the on-call pharmacist, and that prescriptions for lacosamide and Ativan were later signed and faxed to the pharmacy.

Subsequent progress notes indicated that the pharmacy reported the last lacosamide delivery as December 28, 2025, with a 15-day supply, that the pharmacy already had a script for lacosamide, and that lacosamide and Ativan would be included in the next delivery. Resident 1 received a dose of lacosamide from the emergency medication supply on January 18 at 8:00 PM, and a new supply of 60 tablets was received on January 19, with administration resuming that morning. The record showed that Resident 1 had no seizure activity between August 3, 2025, and January 17, 2026, while receiving medications as ordered, and then experienced two seizures with two hospital transfers when lacosamide was not administered as ordered due to the pharmacy’s failure to provide the medication or timely communicate why it could not be supplied when initially ordered. Interviews with the Regional Director of Clinical Services and the DON confirmed that nursing staff had reordered lacosamide on January 12, 2026, that the pharmacy had an active prescription but overlooked filling it, that there was no documentation of pharmacy communication between January 12 and 17, and that staff could not access lacosamide from the emergency supply because the pharmacy would not provide an authorization code while stating there was no current script.

For Resident 2, who had dementia and anxiety disorder and an order for Xanax 0.5 mg every 8 hours, a medication administration note on January 26, 2026, documented that Xanax was not administered while awaiting pharmacy delivery. A nurse’s note later that day recorded that an RN contacted the pharmacy about retrieving Xanax from the emergency medication supply and questioned whether two 0.25 mg tablets could be used to equal the ordered 0.5 mg dose; the pharmacy responded that medications must be dispensed as written. The RN then contacted the physician for further orders, and the pharmacy indicated the medication would be on the next delivery. Another note documented that the physician gave a one-time order for Xanax 0.25 mg, two tablets now. The Controlled Substance Record for Xanax showed the prescription was filled on January 25, 2026, but the Receipt Verification section was blank, and the first dose from that package was not administered until January 26 at 6:30 PM. In an interview, the DON stated she expected medications to be reordered when down to a five-day supply, expected timely dispensing and delivery or immediate notification of issues from the pharmacy, and expected staff to complete the Receipt Verification on controlled substance records. No additional information was provided regarding when staff reordered Xanax or the reason for the delivery delay.