Failure to Administer Ordered Medication and Notify Physician for Dialysis Resident
Penalty
Summary
A resident with End Stage Renal Disease (ESRD) who attends dialysis three times weekly had a physician's order for Renvela 800 mg, to be administered two tablets three times daily at 8:00 a.m., 12 noon, and 5:00 p.m. Review of the Medication Administration Record for April 2025 showed that the 12 noon dose of Renvela was not administered on multiple dates, with documentation indicating the resident was unavailable due to being out of the facility for dialysis. There was no evidence in the clinical records that the resident's physician was notified about the missed doses. The Director of Nursing confirmed that the medication was not given because the resident was at dialysis and that the physician was not informed of the missed administrations. The facility failed to ensure that ordered medications were administered as prescribed to a resident receiving dialysis, and did not notify the physician when doses were missed.