Failure to Ensure Timely Availability of Admission Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed medications were readily available for a newly admitted resident, resulting in multiple missed first doses. The resident was admitted with diagnoses including malignant neoplasm of the lung, T7–T8 vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention. Physician orders dated for the admission included Morphine Sulfate ER 30 mg (2 tablets every 12 hours for cancer-related pain), Flomax 0.4 mg at bedtime for benign prostatic hyperplasia related to urinary retention, Prochlorperazine 10 mg every 8 hours for nausea/vomiting related to lung cancer, and Budesonide-Formoterol 160/4.5 mcg (2 puffs every 12 hours) for COPD-related airway patency. Review of the MAR showed that the evening dose of Morphine ER, the bedtime dose of Flomax, the evening and next-morning doses of Prochlorperazine, and the evening dose of Budesonide-Formoterol on the first days after admission were not administered, with the reason documented as “on order.” During a telephone interview, the complainant reported that the resident waited a significant amount of time for physician orders and missed the first dose of several medications as a result. In an interview, the DON stated that depending on the medication, it was not uncommon to have a delay in prescriptions arriving at the facility, which could result in a missed dose, and explained that the facility maintained only a limited back-up supply and that controlled substances could be delayed if there were issues getting the physician’s order to the pharmacy. The DON also stated that the facility did not always have discharge orders before the resident arrived. Facility policies reviewed indicated that admission orders must include medication orders for immediate care and that the provider pharmacy was required to provide routine and timely pharmacy service, including 24/7 emergency service.
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