Failure to Ensure Proper Administration and Notification for Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for a resident. The resident, a woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had physician orders for several medications including aspirin, doxepin, divalproex, haloperidol, folic acid, multivitamin, and metoprolol. Review of the medication administration record (MAR) showed that multiple doses of these medications were missed on several days, with the MAR indicating the resident was 'away from the facility' during those times. The resident frequently went out on pass, sometimes overnight, and staff interviews revealed that when a resident was out during medication times, the MAR was marked accordingly. However, there was inconsistency in notifying the nurse practitioner (NP) or physician about missed medications, and documentation of such notifications was lacking. Staff interviews indicated that while some nurses believed they should notify the NP or physician and document it in the progress notes, this was not consistently done. The NP confirmed that he was not informed about the resident missing several days of medications and emphasized the importance of such notifications for clinical decision-making. Facility policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications, and documentation of such notifications. Despite this, the review found no evidence that the NP or MD was contacted when the resident returned after missing medications, nor was there documentation in the progress notes. The failure to follow established procedures for medication administration and notification led to the deficiency.