Failure to Obtain and Administer Ordered Psychotropic and COPD Medications After Pharmacy Transition
Penalty
Summary
The deficiency involves the facility’s failure to ensure the acquiring, dispensing, and administration of ordered medications for one resident, resulting in multiple missed doses of an anticonvulsant, an antipsychotic, and a COPD maintenance inhaler. The resident was admitted with diagnoses including COPD, depression, and bipolar disorder and had new physician orders initiated for Divalproex Sodium 1000 mg at bedtime for bipolar disorder, Olanzapine 2.5 mg at bedtime for bipolar disorder, and Trelegy Ellipta one puff daily for COPD. Medication Administration Records (MARs) for several days showed these medications were not administered, with chart codes referencing progress notes that documented the medications were still on order rather than available for use. For Divalproex Sodium, the MAR documented that the medication was not given on two separate days, and nursing notes on those days stated the medication was on order. For Olanzapine, the MAR showed it was not administered on three days, with corresponding notes from two different nurses indicating the medication was on order each time. For Trelegy Ellipta, the MAR documented it was not administered over four consecutive days, with multiple nursing notes stating the inhaler was on order and one health status note indicating the on-call provider was notified that the facility was still awaiting delivery of the medication. On one of the days Trelegy was not administered, there was no corresponding medication administration note in the electronic record. Interviews revealed that nursing staff were aware that the resident had not received all ordered medications after admission and believed medications had been ordered by administrative nurses and were pending delivery from the pharmacy. One nurse acknowledged not checking the Pyxis for availability of medications and did not contact the resident’s family to see if there was a home supply. The DON stated the facility had recently switched to a new pharmacy and believed orders would transmit electronically as with the prior system, and that the facility was not aware the resident’s medication orders had not been transmitted. Pharmacy staff reported that the orders for the resident’s Divalproex, Olanzapine, and Trelegy were not actually received until several days after the orders were written, at which time the medications were delivered, confirming that the medications had not been available during the period they were documented as “on order.”
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