Failure to Ensure Nursing Staff Competency in Immunosuppressant Drug Therapy
Penalty
Summary
Nursing staff failed to demonstrate competency in managing immunosuppressant drug therapy for a resident with a history of heart transplant. Upon the resident's readmission following hospitalization for heart failure exacerbation, the hospital discharge summary specified a revised tacrolimus regimen and required follow-up lab monitoring. However, the facility's medication reconciliation process did not clearly document the resolution of medication discrepancies, and the resident's tacrolimus was discontinued shortly after readmission, resulting in a gap where no doses were administered for over two weeks. The resident missed 40 doses of tacrolimus between late February and mid-March, as evidenced by the medication administration records. Additionally, the required tacrolimus level was not drawn on the specified date, and when it was eventually obtained, the abnormally low result was not promptly communicated to the consulting heart failure team for further recommendations. The lack of timely notification and follow-up led to the resident being transferred to the hospital for organ rejection surveillance and medication adjustments. Interviews and review of staff education files revealed that nurses assigned to the resident's care had not received prior education or in-service training on immunosuppressant medication management or laboratory result reporting. The facility's education binder confirmed the absence of relevant training before the incident. Facility policies required prompt physician notification of abnormal lab results and significant changes in treatment, but these protocols were not followed in this case.