Failure to Notify Physician of Missed Heart Failure Medication Doses
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically when four doses of a prescribed heart failure medication (Entresto) were not available and therefore not administered as ordered. The resident, an elderly female with diagnoses of congestive heart failure and sick sinus syndrome, was admitted from home and required Entresto twice daily. Documentation showed that the medication was not administered on four occasions, and the Medication Administration Record (MAR) indicated this with a code, but there was no written documentation in the resident's electronic progress notes that the physician or nurse practitioner was notified of the missed doses. Interviews with facility staff revealed that the process for handling unavailable medications involved notifying the family to bring in medications from home and checking the facility's medication supply system (pyxis). In this case, the family did not provide the medication, and it was not available in the pyxis. The medication aide documented the missed doses in the MAR but did not inform the assigned nurse, and the nurse did not notify the physician. Both the Director of Nursing (DON) and the regional compliance nurse confirmed that staff were trained to notify physicians when medications were not administered as ordered and to document this notification, but this did not occur in this instance. Further interviews with the medical doctor and medical director confirmed that they were not notified about the missed doses, and facility policy required physician notification when medications were not administered. The lack of communication and documentation regarding the missed medication doses resulted in the physician not being able to provide alternative instructions or treatment for the resident.