Failure to Provide Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic kidney disease, aneurysm of artery of lower extremity, and peripheral vascular disease did not receive a physician-ordered medication, Xarelto 20mg, for atrial fibrillation. The resident was cognitively intact, as indicated by a BIMS score of 15/15. On the specified date, the medication was not administered during the 3:00 p.m. to 11:00 p.m. shift, as shown by a blank entry on the Medication Administration Report. The Director of Nursing confirmed that if a medication is not available, nurses are expected to check backup supplies and contact the pharmacy, and if a dose is missed, the physician should be notified. The Infection Preventionist nurse stated that attempts to borrow the medication from other units were unsuccessful. There was no documentation in the resident's progress notes that the physician was notified of the missed dose. Pharmacy records indicated that a resupply request for the medication was made the following day, and the medication was received from the contracted pharmacy over the next two days. Facility policy requires nurses to follow physician orders and recommendations. The failure to ensure the medication was available and administered as ordered, and the lack of physician notification regarding the missed dose, led to the cited deficiency.
Plan Of Correction
Corrective Action: On 5/22/25, notified PCP that Resident #2 missed a dose of NJ Exec Order 26.4b1; no new orders were given. NJ Exec Order 26.4b1 from not receiving medication. Resident #2 resumed the medication as ordered on NJ Exec Order 26.4b1. On 5/23/25, director of nursing received approval from medical director to have NJ Exec Order 26.4b1 added to back-up box. An audit was conducted on 6/11/25, by the director of nursing on all EMAR progress notes of medications not administered. Discrepancies were identified, addressed, and individual counseling was provided to each nurse. Identification of Residents at Risk: All residents prescribed medication(s) have the potential to be affected by this deficient practice; residents can be identified by reviewing physician's orders. Systemic Change: Facility-wide in-service on proper procedure on requesting a refill for medication in a timely manner & when a prescribed medication is not available was conducted on 6/11/25 with all nurses, by the director of nursing. "Medication Not Available" form was initiated to be completed by nurses and turned into the director of nursing. Quality Assurance: Unit managers, or designee, will conduct an audit on EMAR progress notes to assure proper procedure taken on any medication not administered. Audits will be completed weekly for 2 months, then monthly for 1 year. Any discrepancies will be corrected/ addressed immediately. These audits will be turned into the director of nursing. The results of the EMAR audits will be reviewed by the DON, or designee, weekly for 2 months, then monthly. The findings will be reported to the LNHA and QAA committee quarterly for one year. The QAA committee will review the effectiveness of the implemented corrective actions and determine if further action is needed. If necessary, adjustments to protocols or corrective actions will be made to assure continued compliance and improvement.