F0760

G

Significant Medication Omissions Due to Pharmacy Delays and Transcription Failures

Bennington, Vermont Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including frequent omissions related to medication unavailability and transcription issues. One resident with multiple psychiatric and neurologic diagnoses, including panic disorder, anxiety disorder, dissociative identity disorder, major depressive disorder, tremor, and hypertension, had a physician’s order for Effexor XR 300 mg daily for depression. Review of progress notes and MARs showed this resident did not receive Effexor for several days spanning late December and early January. The same resident also had an order for Pregabalin (Lyrica) 25 mg daily for pain, which was not available and not administered for multiple days. During this period of missed doses, the resident was found on the floor crying, reporting a pounding headache and left hand pain, with a blood pressure of 206/104, pulse 98, and oxygen saturation of 97%, and was noted to have seizure activity twice before being sent to the emergency department.

At the hospital, the resident was admitted for observation with seizure-like activity and elevated troponin and lactic acid levels, and was started on Keppra to prevent further seizure activity. The discharge summary documented suspicion for organic seizure and noted that the patient would be going back on all standard medications, with mention that there was some question about missed medications at the facility based on information from a friend. The resident later returned to the facility with no new orders, and a subsequent communication note documented that Effexor and Lyrica still had not arrived from the pharmacy despite multiple contacts. Additionally, after the resident underwent bilateral laser iridotomy, the surgeon ordered Prednisolone 1% eye drops once daily in each eye for seven days starting the day after the procedure. The January MAR showed that this order was not transcribed until two days after the intended start date and not implemented until the following day, and an SBAR later documented the resident’s complaint of right eye pain and throbbing.

Another resident with anxiety disorder and bipolar disorder had a long-standing order for Depakote DR totaling 1500 mg daily for mood disorder. When this resident’s diet was changed to pureed and staff reported the resident could not swallow the Depakote tablets, 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 the same day, but the Depakote sprinkles were not implemented for 19 days, resulting in the resident receiving no Depakote during that period. A third resident had an order for Pregabalin (Lyrica) 50 mg three times daily for neuropathy, but progress notes documented that the medication was not available for several days, with no documentation that the physician was notified of the missed doses or that monitoring for adverse reactions to abrupt cessation occurred. This same resident later had an SBAR for painful urination, with provider orders for Keflex and Pyridium for suspected UTI; however, the MAR showed that Keflex was not implemented until two days after the order and Pyridium remained awaiting pharmacy on that date. The DON confirmed ongoing issues with the contracted pharmacy not providing prescribed medications and confirmed that these medication errors occurred.

Overall, across these three residents, the survey findings show repeated failures to administer ordered medications as prescribed due to unavailability and delays in transcription and implementation of new orders. These failures included omissions of psychotropic, anticonvulsant, neuropathic pain, ophthalmic, and antibiotic medications over multiple days. Documentation gaps included lack of timely transcription of orders, lack of timely implementation of ordered therapies, and lack of evidence that providers were notified or that residents were monitored for adverse reactions when medications such as Lyrica were abruptly not given. The DON acknowledged the medication omissions and the facility’s ongoing problems with the contracted pharmacy, which contributed to the significant medication errors identified by surveyors.