F0755

G

Widespread Delays and Omissions in Providing Ordered Medications

Bennington, Vermont Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely acquisition and availability of ordered medications, resulting in omitted or delayed physician-ordered drugs for multiple residents. One resident had an order for venlafaxine XR 300 mg daily for depression and did not receive the medication for four days because it was not available, as documented on the MARs and in progress notes. The same resident also had an order for pregabalin 25 mg daily for pain that was not available and not administered for eight days. During this period, a progress note described staff finding the resident on the floor, crying with a pounding headache and left hand pain, with a blood pressure of 206/104, pulse 98, oxygen saturation 97%, and seizure activity observed twice, leading to transfer to the ED. Hospital records showed suspicion for organic seizure, elevated troponin and lactic acid, and a discharge plan that referenced possible missed medications at the facility. The resident later returned from an outpatient laser iridotomy with an order for prednisolone 1% eye drops daily for seven days, but the order was not implemented until two days after the prescribed start date, and there was an additional documented day when venlafaxine was again unavailable.

Another resident had a long-standing order for Depakote DR totaling 1500 mg daily for mood disorder. When the resident’s diet was changed to pureed and they were unable to swallow the Depakote tablets due to size and coating, an on-call provider ordered a change to Depakote sprinkles with dosing to be determined by pharmacy. The original Depakote order was placed on hold pending the new formulation, and the MAR showed that the Depakote sprinkles order was not implemented for 20 days. During this time, the resident did not receive any Depakote, as confirmed by the DON, because the new formulation and dosing were not obtained and started in a timely manner.

A third resident had a physician’s order for pregabalin 50 mg three times daily, with progress notes indicating that the medication was not available over several days. This resident later developed painful urination, and the provider ordered diagnostic tests, IV fluids, and new medications including Keflex 500 mg twice daily for five days and Pyridium 100 mg twice daily for three days. Review of the MAR showed that the Keflex order was not implemented until two days after it was written, and Pyridium remained documented as awaiting pharmacy on that same date. In an interview, the DON confirmed that some medications had not been available for administration as ordered, reported ongoing issues with the pharmacy not delivering medications on time, and identified that an internal audit found 35 of 81 residents with missing medications.