Failure to Ensure Availability of Prescribed Gabapentin Leading to Multiple Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure the availability and delivery of a resident’s prescribed Gabapentin, resulting in eight missed doses over a four-day period. The resident was admitted with diabetes mellitus with diabetic polyneuropathy and had a physician’s order for Gabapentin 800 mg by mouth three times daily for neuropathy related to diabetes. Review of the MAR showed that multiple scheduled doses on several consecutive days were documented as not administered because the medication was unavailable. On one morning, a medication aide found that the Gabapentin was not in the medication cart, reordered it in the electronic charting system, and did not recall whom she informed about the missed dose. On two night shifts, a nurse also found the medication absent from the cart, knew the dispensing machine did not have enough Gabapentin to cover the ordered dose, and did not reorder from the pharmacy or contact the pharmacy to check on the medication status, assuming day shift would handle reorders. Another nurse reported that on a later date the morning dose was not in the cart, that medication aides could not access the dispensing machine, and that staff were trying to piece together doses from the machine; she stated the resident eventually refused a noon dose and acknowledged she did not personally contact the pharmacy and was unaware of the multiple missed doses. Further observations showed that the dispensing machine contained only two 300 mg Gabapentin tablets and no 100 mg tablets, which was insufficient to provide one full scheduled dose. A medication aide reported that the Gabapentin had been missing from the cart for at least three days and that the resident had missed both morning and noon doses on one of those days due to unavailability. The unit manager stated no staff had informed her that the resident was missing medication, although she could have pulled from the dispensing machine if available. The pharmacist reported that a 30‑day supply had been delivered earlier in the month, that an electronic reorder on one of the dates was too early for insurance refill, and that the facility could have requested medication billed to the facility, but no one from the facility called to check on the status. The DON and Administrator both stated that nursing staff were responsible for reordering and should have called the pharmacy after the medication was not received, and confirmed that the resident should not have been missing doses of the high‑dose Gabapentin.
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