Failure to Notify Resident and Physician of Missed Medication Doses
Penalty
Summary
The facility failed to notify a resident and the resident's primary care physician (PCP) of missed medication doses for one resident. The resident, an 82-year-old male with a history of peripheral vascular disease and pulmonary embolism, did not receive prescribed doses of Warfarin, a blood thinner, from March 24 through March 27, 2025. The Medication Administration Record (MAR) showed no Warfarin order during this period, and a new order was placed on March 28, 2025. The resident reported not being informed about the missed doses, and the PCP confirmed not being notified of the missed medication. The PCP stated that, had he been informed, he would have ordered lab tests and adjusted the medication accordingly. Additionally, the resident's emergency contact (family member) stated they were not notified about the missed medication doses, although they had been contacted for other significant events in the past. Progress notes indicated that a new Warfarin order was placed, but there was no documentation of physician notification regarding the missed doses. The Director of Nursing acknowledged that the physician should have been notified when it was realized the resident had not received the prescribed medication.