Failure to Ensure Timely Refill and Administration of Pramipexole for RLS
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of pramipexole for a resident with restless leg syndrome (RLS) and seizures. The resident was admitted in January 2026 and had intact cognition, as evidenced by a Brief Interview for Mental Status score of 15 out of 15. A physician’s order dated 1/23/2026 directed that pramipexole dihydrochloride 0.5 mg, two tablets by mouth twice daily, be administered for RLS. Review of the February 2026 Medication Administration Record showed that this medication was not administered as ordered on nine occasions between 2/8/2026 and 2/12/2026, with doses missed on multiple mornings and afternoons. The resident reported going about three days without receiving pramipexole because it was not available, and stated that this resulted in uncomfortable leg sensations, pain radiating to the back, and the need to pace around the unit due to discomfort when sitting still. A progress note dated 2/11/2026 documented that the pharmacy failed to deliver the ordered pramipexole and that the resident requested transfer to the Emergency Department to access the medication. During interviews, the Director of Nursing Services acknowledged that the medication was not administered as ordered on the identified dates because it was unavailable from the pharmacy, and the Pharmacy Account Manager stated that the refill request for pramipexole was not submitted by the facility until 2/12/2026.
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