Failure to Notify Physician of Missed Cancer Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was appropriately notified of multiple missed medication doses for a resident with a history of prostate cancer, high blood pressure, and depression. The resident had a physician order for Nubeqa, a medication used to decrease the growth and spread of prostate cancer, to be administered twice daily. Review of the Medication Administration Record showed that the medication was not administered over several consecutive days due to it being unavailable, with documentation indicating reasons such as the medication being reordered but not yet arrived, family to provide, or simply unavailable. On one occasion, the medication was not administered due to resident refusal. Despite the ongoing unavailability of the medication, there was no documentation that the physician was notified of the missed doses, as confirmed by the Director of Nursing. Facility policy required immediate action to obtain unavailable medications and to notify the physician and resident/family when there was a need to alter medical treatment, including changes in provider orders. The resident was his own responsible party and had declined to allow the facility to communicate with his brother regarding the medication, further complicating the situation. However, the lack of physician notification regarding the missed doses constituted a failure to follow facility policy and regulatory requirements.