Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to obtain physician ordered medications for two of five residents reviewed (Residents 1 and 3).Findings include:
Clinical record review for Resident 1 revealed the resident was admitted to the facility on April 19, 2024, at 3:36 PM.
Review of Resident 1's admission physician orders for medications to be administered to the resident revealed the following medication were ordered on April 19, 2024:
Bupropion HCL ER 150 mg (milligrams) tablet two times a day for depression to start April 19, 2024, at 8:00 PM
Phos-NaK oral packet 280-160-250 mg (Potassium and Sodium Phosphate) one packet with meals to start April 19, 2024, at 6:00 PM
A review of Resident 1's medication administration record for April 2024, revealed no evidence the above medications were administered as ordered. The medication administration log was blank for the administration dates and times indicated. There was no evidence to indicate why the doses were not administered.
Clinical record review for Resident 3 revealed the resident was admitted to the facility on May 3, 2024, with nursing admission assessment completed at 2:00 PM.
A review of Resident 3's admission physician ordered medications revealed the resident was ordered the following medications on May 3, 2024, to start at 9:30 PM:
Amitriptyline HCL 25 mg to be given at bedtime for depression.
Calcium-Vitamin D 600-200 mg unit two times a day for supplementation
Diclofenac Potassium 50 mg one tablet three times a day for back pain
Lorazepam tablet 1 mg at bedtime for anxiety
Pregabalin capsule 100 mg three times a day for pain management.
A review of Resident 3's medication administration record for May 2024, revealed no evidence Resident 3 was administered the above medication for the dosage and time indicated above. The medication administration record was left blank for the dates and times indicated for the above medications. There was no documented evidence as to why Resident 3 should not have received the medications as ordered.
In an interview with the Nursing Home Administrator and Director of Nursing on May 8, 2024, at 12:30 PM the Director of Nursing indicated all medication orders are sent to the facility's pharmacy via the electronic record and medication deliveries arrive twice a day between 3:30-4:30 PM, and midnight - 2 AM. The Director of Nursing indicated since the pharmacy deliveries for the afternoon are already in route, residents admitted to the facility during the day have medications arrive on the midnight - 2 AM delivery. The Director of Nursing indicated some medications are available in the facility pharmacy stock, but not all that are ordered are available to utilize until medication deliveries arrive at the facility.
In a follow up interview with the Director of Nursing on May 8, 2024, at 2:30 PM it was confirmed Residents 1 and 3 were not administered the above medications as ordered.
28 Pa. Code 211.9 (f)(4)(k) Pharmacy services
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
