F0755

D

Failure to Ensure Availability of Essential Pancreatic Enzyme Medication

Cumberland, Maryland Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure that a resident with pancreatic cancer who had undergone a Whipple procedure consistently received the prescribed pancreatic enzyme medication, Creon, upon admission and throughout the stay. The hospital discharge summary documented the need for Creon with meals to assist with digestion and nutrient absorption, and the resident’s orders specified Creon capsules three times daily. Review of the MAR showed multiple missed doses on specific dates when the medication was not administered because it was not available, with nurses documenting that the drug was not available from the pharmacy, was on order, or was pending physician evaluation. On the day of admission, the assigned RN did not administer Creon because it had not been ordered from the pharmacy and documented the missed dose accordingly.

Pharmacy dispensing records showed that Creon was shipped in 100‑capsule quantities on three separate dates, which coincided with documented missed doses when the facility allowed the supply to run out before refills arrived. The DON acknowledged awareness prior to admission that the resident required Creon and its importance with each meal, yet there was no process in place to ensure the medication was available at admission or to prevent running out between refills. The DON reported that staff asked the family to provide the medication from home and that special‑order medications took longer to obtain because they required her signature and were not stocked at the pharmacy. The facility’s policy on ordering and receiving medications lacked an implementation date and did not include provisions for special‑order medications, and there was no documentation that the hospital case manager had instructed the family to bring the medication at admission.