Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering Entresto Oral Tablet as ordered for a resident with congestive heart failure and sick sinus syndrome. The resident was admitted on a Friday evening, and the facility's pharmacy did not deliver medications on weekends. The facility requested the resident's family to bring in the medication from home, but the Entresto was not provided. The medication was also not available in the facility's pyxis system. As a result, the medication was not administered on multiple scheduled occasions, as documented in the Medication Administration Record (MAR). Interviews with the DON, LVN, and medication aide revealed that the medication aide did not inform the nurse that the medication was not administered, and the nurse did not notify the physician or document the missed doses as required by facility policy. The facility's policy states that if a regularly scheduled medication is withheld or refused, an explanatory note must be entered in the nursing notes or the PRN nurses notes section of the MAR. The medical director confirmed that staff are required to notify physicians when medications are not administered as ordered.