Medication Not Administered as Ordered with Meals
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, anemia, and diabetes mellitus did not receive their prescribed calcium acetate medication as ordered. The physician's order specified that calcium acetate, a phosphate binder, should be administered with meals to treat hyperphosphatemia. On the day in question, the resident's medication was given before lunch was delivered, and the resident did not eat the lunch meal. This was confirmed through interviews with the resident, a CNA, and the nurse who administered the medication. The resident stated she received her medication before food arrived and subsequently refused to eat lunch, which was verified by the CNA who removed the untouched tray. The nurse acknowledged administering the medication before the meal and not ensuring the resident was eating at the time, contrary to the physician's order and facility policy. The facility's policy requires medications to be administered according to prescriber orders and at times that optimize therapeutic effect, not for staff convenience. The failure to administer the medication with food, as ordered, was also confirmed by the RN, who stated that the medication should have been given with the meal to ensure effectiveness.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 29 was assessed by DON and graham crackers were given on 06/12/25. Dietary Supervisor provided a quesadilla. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON found no other resident affected by this deficient practice. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: On 06/16/25 a 1:1 Inservice with LVN 4 by DON and Pharmacy consultant regarding the use of Calcium Acetate and Phosphate binders and the importance of medications being given with food. Observation with Pharmacy Consultant will randomly observe Medication Pass twice a month per Facility Policy. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON and or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.