Failure to Prevent Significant Medication Error Due to Unavailable Cancer Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Nubeqa, a medication prescribed to decrease the growth and spread of prostate cancer. The resident, who had diagnoses including high blood pressure, depression, and a history of prostate cancer, had a physician's order for Nubeqa 600 mg by mouth twice daily. Review of the Medication Administration Record for April showed that the medication was not administered on multiple occasions due to it being unavailable, with documentation indicating issues such as the medication not arriving, the family being responsible for supply, and ongoing unavailability. Interviews with the Director of Nursing revealed that the resident's brother had previously provided the medication out-of-pocket, but was no longer able to do so. Although another family member was willing to assist, the resident, who is his own responsible party, refused to allow the facility to communicate with his brother or provide direction on how to obtain the medication through the facility's pharmacy. As a result, the resident missed numerous doses of the prescribed cancer medication over several days, constituting a significant medication error as required by facility policy and state regulations.