Failure to Provide Timely Access to Prescribed Medications After Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmaceutical services provided timely access to prescribed routine medications for two residents after admission, resulting in multiple missed doses due to medications being unavailable. One resident with diagnoses including anxiety, bipolar disorder, and panic disorder reported not receiving all prescribed medications since admission. Record review showed this resident had physician orders for methadone hydrochloride for chronic pain and Lyrica for anxiety, but the March 2026 MAR documented that methadone 10 mg (one tablet in the morning) was not administered on two dates, methadone 10 mg (three tablets in the morning) was not administered on two subsequent dates, and Lyrica 150 mg three times daily was not administered for all three doses on two consecutive days, all due to the medications being unavailable. Nursing notes indicated that on one of those days the nurse called the pharmacy about the Lyrica and methadone, and the pharmacy reported they needed prescriptions. Another resident with paraplegia, chronic pain, and anxiety reported going nearly a full day without any routine medications following admission. Record review showed this resident had physician orders for buspirone 5 mg twice daily and Lyrica 150 mg three times daily, but the February 2026 MAR documented that buspirone was not administered for one evening and the following morning dose, and Lyrica was not administered for one night dose and all three doses the following day, again due to the medications being unavailable. In an interview, the DON stated that if residents are admitted later in the day and physician orders are not sent to the pharmacy before the evening of admission, residents may not receive their medications until the following evening, and that if medications are not available, staff should obtain them from the emergency drug kit if available. The facility’s pharmacy services policy indicated that the pharmacy is to provide routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week.
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