Failure to Administer Medications as Ordered Due to Inadequate Medication Procurement and Notification
Penalty
Summary
The facility failed to meet professional standards of quality by not administering medications as ordered by the physician for one resident. The resident, who had diagnoses including diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of parts of the digestive tract, had physician orders for fiber tablets and Questran to manage their gastrointestinal conditions. Despite these orders, the medication administration records showed multiple instances where both fiber and Questran were not administered as prescribed over several weeks. Documentation in the medication administration record and progress notes indicated that staff repeatedly noted the medications were not available and were waiting for delivery from the pharmacy or local store. However, there was no documentation that staff took further steps to obtain the medications in a timely manner, such as contacting the pharmacy, notifying the staff member responsible for purchasing over-the-counter medications, or escalating the issue to ensure the resident received the ordered therapy. Additionally, staff did not consistently notify the provider about the missed doses, as required by facility policy, with only one documented instance of provider notification after several missed doses had already occurred. Interviews with nursing staff and the DON confirmed that the expected procedures for medication shortages were not followed. Staff were expected to notify the provider and document communication for each missed dose, as well as to contact the pharmacy or arrange for over-the-counter medication purchases. The facility's own policy required these actions, but records and interviews showed that these steps were not consistently taken, resulting in the resident missing multiple doses of prescribed medications.