The breakdown began on May 25, when Resident #149's prescribed hypnotic medication was not available in the facility's automated dispensing system. The nurse documented that pharmacy was notified, but what happened next revealed a web of miscommunication between facility staff, pharmacy, and physicians.
Pharmacist #25 contacted the physician and received an electronic prescription from an on-call provider for just a three-day supply of zolpidem. The pharmacist saw no evidence of follow-up with the provider until a fax was sent on May 27 — two days later. A valid prescription finally arrived on June 2, and 10 pills were delivered to the facility.
That meant Resident #149 went without the prescribed sleep medication for over a week.
The facility's Director of Nursing told inspectors she was unaware the resident's medication had been unavailable. She said the facility contacted an on-call nurse practitioner who called the pharmacy and gave an order for three zolpidem, but neither staff nor pharmacy called to get another prescription when that ran out.
"It was not the facility's standard not to administer medications," the Director of Nursing stated. She said she expected staff to call the physician and get a prescription or reach out to her for assistance so they could give the resident their medication.
But staff and pharmacy each pointed to the other for responsibility.
Registered Nurse #5 told inspectors the pharmacy notified the facility when medications were missing or new prescriptions were needed. The nurse said the facility communicated needs "as soon as possible" or had pharmacy contact the physician directly. RN #5 emphasized it was "critical for medications to be delivered timely, particularly when they were not available in the Pyxis."
Unit Manager #3 said that upon admission, medication orders were sent to pharmacy, which usually delivered medications the same night. If medication wasn't in the automated system, he said, nurses must call pharmacy, and delivery typically occurred within two hours.
The pharmacist saw it differently. Pharmacist #25 said when prescriptions were needed, the pharmacy contacted the provider. But after getting that initial three-day supply, the pharmacist waited for the facility to follow up.
The Administrator blamed the pharmacy entirely. On September 18, the Administrator told inspectors that regarding Resident #149's medication, "they expected the pharmacy to either send the medication or notify the facility if assistance was needed to obtain a prescription."
The facility's own policy contradicted this finger-pointing. A January 2023 policy titled "Ordering of Drugs" stated the purpose was "to assure that the pharmacist dispenses and labels medications properly, assure correct financial responsibility and prompt delivery of drugs." The policy required that "any shortage or irregularity with the order is documented and made known to the pharmacist on call by telephone."
The Director of Nursing acknowledged what should have happened. She said best practice was to have signed prescriptions available on admission so staff could fax them to pharmacy and have medications delivered that evening.
Instead, Resident #149 experienced a medication gap that stretched over a week. The prescribed hypnotic — typically used to treat insomnia and sleep disorders — remained unavailable while staff, pharmacy, and physicians failed to coordinate a solution.
The breakdown occurred despite multiple staff members understanding the importance of timely medication delivery. RN #5 called it "critical." Unit Manager #3 described a system where delivery typically occurred within two hours of a pharmacy call. The Director of Nursing outlined clear expectations for staff to contact physicians or supervisors when medications weren't available.
None of that happened for Resident #149.
The complaint that triggered the inspection revealed a pattern where communication failures left residents without prescribed medications. Federal inspectors found the facility failed to ensure medications were available as prescribed, a violation that affects residents' health and wellbeing.
The case illustrates how bureaucratic finger-pointing can leave vulnerable residents without essential medications while staff debate whose job it is to make the necessary phone calls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritagespring Healthcare Center of West Chester from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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