Failure to Ensure Continuous Supply of Prescribed Controlled Medication
Penalty
Summary
Failure to maintain effective systems for acquiring and refilling a controlled medication resulted in a resident missing four consecutive days of a prescribed drug. The resident, admitted with diabetes mellitus and neuropathy, had an order for Lyrica 25 mg once daily for neuropathy. Review of the MAR showed that the 9:00 AM dose of Lyrica was not administered on four specific days, each omission coded to refer to progress notes. Progress notes on each of those days, written by different nurses, documented that the Lyrica was "on order," indicating the medication was unavailable for administration. Multiple nursing staff reported they did not have the Lyrica available on their shifts and documented or reported that the medication was on order. One nurse stated she reordered the medication from the pharmacy and informed the Weekend Supervisor, who later did not recall being notified. Another nurse reported she requested a refill from the Unit Manager, contacted the pharmacy to attempt to pull the medication from the Pyxis, and was told there was no prescription on file, preventing access to the backup supply. She stated she notified the Unit Manager on two separate days that the resident was out of Lyrica and that it could not be pulled from the Pyxis. A third nurse reported she also did not have the Lyrica to administer and stated she informed the Unit Manager. The Unit Manager described a process in which nurses were to call the pharmacy for refills, and the pharmacy would either send the medication or indicate a new prescription was needed. She stated that full-time nurses typically informed her when a new prescription was required, but agency nurses often did not know how to do this, requiring repeated education. She reported being informed that the resident was out of Lyrica, contacting the pharmacy, and being told the medication would be sent, then later being told a new prescription was needed. The Nurse Practitioner stated he received email requests from the facility when controlled medications needed reordering and that he checked these multiple times daily. The Pharmacy Director reported that the last refill of 30 capsules had been delivered previously, that a more recent refill required a new prescription, and that there was no record of an early refill request; she stated that if facility procedures had been followed, there was no reason the medication should have run out. The DON and Medical Director both acknowledged awareness that the resident’s medication had run out, with the Medical Director stating that running out of residents’ medications should never happen.
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