Failure to Adjust Medication Times for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident requiring dialysis by not adjusting medication administration times to accommodate the resident's dialysis schedule. The resident, who had a history of chronic kidney disease, end-stage renal disease, and hypertension, was on a dialysis schedule of Tuesday, Thursday, and Saturday. Despite this, the facility did not ensure that the resident's medications were administered at times that would not conflict with the dialysis schedule. The resident's electronic medication administration record (EMAR) showed that medications such as Sevelamer Carbonate and Hydralazine were not administered on days when the resident was out for dialysis. The Licensed Practical Nurse (LPN) confirmed that the medications were not given because the resident was out for dialysis, and there was no documentation of the reason for the missed doses in the electronic progress notes. The facility's procedure required medication times to be adjusted for residents out for dialysis, but this was not consistently done. Interviews with the facility's staff, including the Consultant Pharmacist and the Unit Manager/Registered Nurse, revealed that there was a lack of communication and follow-through in adjusting medication times. The Licensed Nursing Home Administrator and the Director of Nursing acknowledged the oversight, and it was noted that the facility's policies did not specifically address medication timing adjustments for dialysis. This deficiency in care was identified through observation, interview, and record review by the surveyor.
Plan Of Correction
1. The medication administration records (MARS) for resident #56 were immediately reviewed by the Director of Nursing with the Administrator to ensure the medication administration times were adjusted appropriately to accommodate the NU EX Ordar 26 schedule. The attending physician of resident #56 was notified on 12/18/24 of the medication timing issues on & and the missed doses of medications: On and the doses for NJ Ex Order 26.4(b)(1) at 2:30pm was not administered. On and the doses for NJ Ex Order 26.4(b)(1) at 2pm were not administered. On and the dose for NJ Ex Order 26.4(b)(1) was not administered at 12 noon. An in-service education was conducted by the Director of Nursing for all nursing staff involved in medication administration for Resident #56 on 12/19/24. The training emphasized the importance of coordinating medication times with dialysis schedules, identifying medications affected by dialysis, and reviewing physician orders for specific instructions. Attendance was documented. A root cause analysis was conducted to identify the underlying causes of the deficient practice. It was determined from RCA that the underlying cause was lack of education/training of agency nurses on adjusting the timing of medication for individuals on dialysis to accommodate dialysis schedules. It was also identified that adjustment of timing of medication was not included in the dialysis policy. 2. All dialysis patients have the potential to be affected by the same deficient practice. No other dialysis residents were identified in the facility. 3. The facility's Dialysis Policy and Procedure was revised on 1/7/24 to include: Adjustment of medication administration times per doctors order to accommodate dialysis schedule. A process for clear communication between the dialysis unit and the facility nursing staff regarding medication administration. All nursing staff will be re-educated on the revised policy and procedure by 1/15/24. The facility orientation process of agency nurses will be revised to add the updated Dialysis policy to general orientation of agency nurses upon hire and annually. The updated Dialysis Policy will be included in the general orientation and annual education for all clinical team members. The unit manager will check the medication administration record of patients on dialysis to ensure the medication administration time is adjusted to accommodate the dialysis schedule. Pharmacy consultant to review the dialysis medication administration record to ensure proper medication times and any identified concerns with medication adjustment will be immediately communicated verbally to the administrator or Director of Nursing. During the daily clinical meeting, the medication administration record of each dialysis resident will be reviewed by the clinical team for appropriate adjustment of medications. 4. The Director of Nursing, or designee, will audit 2 agency nurse's education files monthly for one year to ensure that education on the dialysis policy was provided. The Director of Nursing, or designee, will audit the medication administration record of all dialysis patients weekly and ongoing for one year for proper medication administration time adjustment to accommodate dialysis schedule. The Director of Nursing will report the audit results to the QAA Committee quarterly and to the QAPI team monthly.