Failure to Administer Immunosuppressive Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral lung transplant and mild cognitive impairment did not receive Tacrolimus, an immunosuppressive medication, as ordered by the physician. The resident's care plan included the administration of Tacrolimus to prevent shortness of breath related to the lung transplant, and the physician's orders specified the medication should be given twice daily. However, the medication was placed on hold and not administered on a specific date, as documented in the Medication Administration Record. The sequence of events leading to this deficiency began when a family member requested that the medication be held due to an upcoming appointment and blood test. A registered nurse received this request and relayed it to a licensed vocational nurse but did not contact the physician to obtain an order to hold the medication. The physician later confirmed that he was not notified of the request and emphasized that Tacrolimus is necessary to prevent lung transplant rejection. The facility's policy required medications to be administered according to prescriber orders, which was not followed in this instance.