Failure to Notify Provider of Missed Medication Doses for Resident with Diarrhea
Penalty
Summary
The facility failed to notify the provider when a resident missed multiple doses of prescribed medications intended to manage diarrhea and promote colon health. The resident, who had a history of diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of digestive tract parts, was admitted with orders for Questran and fiber tablets. Over a period in March and April, the resident missed at least 8 doses of Questran and 12 doses of fiber, as documented in the medication administration record (MAR). Progress notes repeatedly indicated that the medications were not available and that staff were waiting for pharmacy delivery, with nurses being made aware of the situation. However, there was no documentation that the provider was notified about the missed doses of either Questran or fiber during this time. The only provider notification occurred after several missed doses, when staff contacted the on-call provider, who then ordered an alternative medication (Imodium A-D). Interviews with staff confirmed that the standard process required notifying the provider and documenting the communication whenever a resident missed any medication doses. The Director of Nursing verified that, prior to the eventual notification, staff had not contacted the provider regarding the missed doses of Questran or fiber, and that such notification should have occurred at the time of each missed dose.