Failure to Clarify Provider Order After Pharmacy Medication Substitution
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not clarifying a provider's order for a resident. Specifically, a physician's order directed that a resident with renal failure and peripheral vascular disease receive 250 mg of calcium citrate twice daily for Vitamin D deficiency. However, during medication administration, the resident was given 950 mg of calcium citrate containing 200 mg of calcium, which did not match the original order. The pharmacy had substituted the medication due to a backorder but did not notify the facility or ensure the substitution was equivalent. Nursing staff, including an LPN, were unaware of the reason for the substitution and did not clarify the change with the physician. There was no documentation in the resident's clinical record indicating that the order was clarified, and the DON confirmed that the medication administered did not match the physician's order. The facility's policy required that such substitutions be communicated and orders updated, but this process was not followed, resulting in the administration of a non-equivalent medication without proper provider clarification.