Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
The facility failed to notify the provider when a resident did not receive multiple doses of prescribed medications, specifically Metoprolol Succinate ER and Quetiapine Fumarate, due to the medications not being available. Documentation showed that over several days, the resident missed doses of both medications, but there was no evidence in the nursing progress notes that the provider had been notified of these missed doses. Interviews with nursing staff revealed that some nurses did not notify the provider, with one nurse stating it was the resident's first night and another indicating that weekend on-call providers would attribute the issue to pharmacy delivery rather than requiring intervention. The nurse practitioner confirmed only partial notification and was not informed of all missed doses. The resident involved had a complex medical history, including chronic systolic heart failure, type 2 diabetes with peripheral angiopathy, hypertensive heart disease with heart failure, and unspecified dementia with agitation. The facility's Director of Nursing and Administrator both stated that they would expect nurses to notify the provider of missed doses of these medications. Despite this expectation, the lack of timely provider notification for missed medication doses was confirmed through record review and staff interviews.