Missed Dose of Cardiac Medication Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident with a history of paroxysmal atrial fibrillation, pneumonia, and chronic diastolic heart failure did not receive a scheduled dose of Flecainide Acetate 50 mg, an antiarrhythmic medication ordered to be administered twice daily. The medication was not given as ordered on the evening of 03/11/25 because it could not be located in the medication cart. The nurse on duty was unable to find the medication, did not administer it, and could not recall if the resident's cardiology service was contacted. The nurse stated the medication was eventually found in an inconspicuous place in the cart, but not in time for the scheduled dose. Documentation indicated that the pharmacy was contacted after the missed dose, and the supervisor was notified, but the medication could not be reordered by the nurse at that time. The resident's care plan identified her as being at risk for decreased cardiac output and abnormal lab values related to her cardiac conditions, with interventions including medication administration as ordered and monitoring for cardiac symptoms. The resident was cognitively intact and required some assistance with activities of daily living. Interviews with staff confirmed the missed dose and the importance of the medication, although the nurse practitioner felt that missing a single dose would not likely cause immediate harm. The facility's review determined that only one dose was missed, and the medication was subsequently located.