Failure to Provide and Administer Prescribed Medications for Dialysis Residents
Penalty
Summary
The facility failed to ensure that routine medications were available and administered as ordered for two residents receiving dialysis. For one resident with end stage renal disease, hyperlipidemia, and gastro-esophageal reflux disease, several prescribed medications were not present in the medication cart, including atorvastatin, famotidine, Nephro-Vite Rx, sevelamer hydrochloride, and metoclopramide. Instead, staff administered alternative medications not matching the physician's orders, such as using a higher dose of famotidine labeled for another resident, substituting regular multivitamins for Nephro-Vite Rx, using sevelamer meant for a discharged resident, and giving a lower dose of metoclopramide than prescribed. For another resident with end stage renal disease and chronic pain syndrome, the required medications calcium carbonate 1250 mg and nortriptyline 75 mg were not available in the medication cart. Staff administered a lower dose of calcium carbonate than ordered. The facility's policy required medications to be reordered five days before they were needed, but this process was not followed, resulting in the unavailability of necessary medications for these residents.