Failure to Administer and Report Missed Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident was not administered multiple prescribed medications, including Allopurinol, Duloxetine, Empagliflozin, Linagliptin, and Rifaximin, as ordered by the physician. The Medication Administration Record (MAR) indicated that these medications were not given due to their unavailability, coded as 'code 11.' The licensed nurse did not document any notification to the prescribing physician regarding the missed doses, nor was there evidence that the provider was informed of the situation. The resident involved had a medical history that included encephalopathy, diabetes mellitus type 2, liver cirrhosis, chronic gout, anxiety disorder, and recurrent major depressive disorder. The resident was assessed as having no cognitive impairment according to the Brief Interview for Mental Status (BIMS) score. Despite the resident's complex medical needs, the required medications were not administered, and the necessary communication with the physician was not documented. Facility policy required that nursing staff notify the attending physician when medications are unavailable, explain the circumstances, and obtain new orders or alternative therapies. The policy also required documentation of this communication and timely administration of medications. Both the Licensed Vocational Nurse and the Director of Staff Development confirmed that these procedures were not followed, and the nurse failed to adhere to professional standards and facility policy regarding missed medication doses.