Failure to Follow Up on Medication with Black Box Warning
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for a resident. The resident was admitted with a prescription for a medication that was not sent by the pharmacy due to the black box warning. The Licensed Practical Nurse (LPN) noticed the medication was out and placed a STAT order, but the issue had been ongoing since the resident's admission. The Director of Nursing (DON) was informed and contacted the pharmacy, which revealed they were waiting for a response from the facility regarding the black box warning. The DON then reached out to the Primary Care Provider (PCP), who deferred the decision to discontinue the medication to the resident's Advanced Registered Nurse Practitioner (ARNP). The ARNP stated that if contacted earlier, she would have recommended discontinuing the medication upon admission. The facility's policy on medication shortages was not followed, as the nurses did not collaborate with the pharmacy and physician to determine a suitable therapeutic alternative. The pharmacist confirmed that the facility should have contacted them to understand why the medication order was not completed.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication warnings have the potential to be affected by not following up on a physician order. Residents with black box sever interactions were reviewed for any missing, late, ordered or not available medications. Physicians will be notified if indicated. Director of Nursing/Designee will in-service the licensed staff on the facility process if a medication is unavailable from Pharmacy due to formulary coverage, contraindications, drug-drug interactions, drug interaction, black-box warnings or other clinical reason. The facility will collaborate with the Pharmacy and physician/prescriber to determine a suitable therapeutic alternative if needed. This in-service will also have a focus on reporting medications not available in Grand Rounds and in the morning clinical meeting. The Unit Managers/Designee will complete 5 random weekly audits on residents with black box sever interactions to ensure follow up with the physician has been completed and the medication is available if medication is approved for the resident. Results of the audits will be tracked trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.