Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to notify a resident's physician when a prescribed medication, Systane night ophthalmic gel, was not available and therefore not administered for two consecutive days. The resident, who had diagnoses including Parkinson's disease, hypotension, and bipolar disorder, was cognitively intact and independent in activities of daily living. The medication was ordered to be instilled in both eyes at bedtime for dry eyes, but the Medication Administration Record showed it was not given on two specified dates due to the medication not being delivered. During interviews and record reviews, the Licensed Vocational Nurse confirmed that the medication was unavailable and had not been administered, and also acknowledged that the resident's physician had not been informed of the missed doses. The Director of Nursing stated that facility policy requires nurses to notify physicians when medications are not available, as this could affect the resident's plan of care. The facility's policy on physician notification was reviewed and supported this requirement.