Failure to Notify Physician of Missed Steroid Dose for Allergic Reaction
Penalty
Summary
The facility failed to notify the physician when a one-time dose of methyl prednisolone, ordered for the treatment of an allergic reaction, was not administered as prescribed. Nursing staff documented that the medication was on order but did not inform the physician of the delay or request further instructions. The medication, intended to address a worsening rash, increased redness, hives, itching, and a low-grade fever, was not given until five days after it was ordered. The nurse initialed the Medication Administration Record (MAR) and noted the medication was on order, but did not communicate the missed dose to the physician as expected. The resident involved had a history of heart failure, hypertension, and chronic pain, and developed a severe rash after starting an antibiotic. The rash worsened over several days, spreading and causing significant discomfort, including intense itching and skin peeling. Despite the resident's deteriorating condition and the nurse practitioner's expectation for prompt administration or notification if the medication could not be given, the physician was not notified of the delay, resulting in a significant lapse in care.