Failure to Provide Timely Medication
Penalty
Summary
The facility failed to ensure the timely provision of physician-ordered medications for a resident. The resident, who was admitted with chronic heart failure, gout, and deconditioning, had a physician's order for the medication Entresto to be administered twice daily starting January 3, 2025. However, a review of the Medication Administration Record (MAR) for January 2025 revealed that the medication was not provided by the pharmacy until January 9, 2025. As a result, the resident did not receive the prescribed medication from January 4 through January 8, 2025. This lapse in medication administration was identified during a clinical record review, indicating a failure in the facility's pharmaceutical services to meet the needs of the resident as required by federal and state regulations.
Plan Of Correction
Corrective Action for cited Resident: Resident #1 was identified and discharged the facility on January 10th, 2025. Other Residents at Risk: An Audit was completed for patients residing in the facility for pharmacy concerns and pharmacy concerns corrected. Systemic Change: Licensed nurses educated on facility policy regarding the review of medication administration and the process to notify pharmacy and on call provider when medication is unavailable. Ongoing Monitoring: DON/designee will audit the EMAR administration record weekly x4 and monthly x2. The DON/Designee will provide in-service and training if deficient practice is noted. The DON/Designee will present the findings of these audits to the QA Committee for review and recommendations. DON is responsible for maintaining compliance.
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