§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.
§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-
§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.
§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and
§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
|
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician ordered medication was available from the pharmacy for two of seven sampled residents. (Residents 1, 7)
Findings include:
Clinical record review revealed that Resident 1 was admitted to the facility on February 7, 2026, with diagnoses that included neoplasm (tumor) related pain and pancreatic cancer. A review of the care plan revealed interventions for staff to administer medications as ordered by the physician. On February 7, 2026, a physician ordered for staff to administer oxycodone (a pain medication) every three hours as needed for severe pain. On February 9, 2026, a nurse noted that the resident complained of pain and that she was unable to administer the oxycodone medication because it was unavailable.
Clinical record review revealed that Resident 7 was admitted to the facility on February 5, 2026, with diagnoses that included polyneuropathy (damage to nerves caused by diabetes) and diabetes. On February 5, 2026, a physician ordered for staff to administer insulin glargine (medication to treat diabetes and maintain blood sugar levels) at bedtime, metoprolol tartrate (blood pressure medication) two times a day, metformin (medication to manage blood sugar levels) two times a day, and gabapentin (medication to treat nerve pain) two times a day. On February 5, 2026, a nurse documented that the mediations were unavailable from pharmacy and therefore not administered.
In an interview on February 17, 2026, at 12:30 p.m., the Director of Nursing confirmed that the medications had not been administered as ordered by the physician because they had not been available from the pharmacy, and that staff should have utilized the emergency supply.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(1)(3) Management.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/23/2026
1) R1 and R7 had no lasting ill effects from unavailable medication.
2) Comprehensive audits of residents' progress notes for the last 7 days to assess if medications were marked as unavailable with follow up as needed.
3) Education of licensed staff on the unavailable medication policy, what medications are in the emergency supply, and the use of emergency supply machine.
4) An audit 5x per week times 2 weeks, then weekly times 2 weeks, then monthly times 2 of residents' progress notes to assess if meds were unavailable with proper follow up.
5) Results will be reported to QPAI until compliance is achieved.
|
|
