Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering Farxiga as ordered by the physician for three consecutive days. The resident, who had diagnoses including type 2 diabetes mellitus, congestive heart failure, ischemic cardiomyopathy, and chronic kidney disease, did not receive the prescribed medication on three occasions. Documentation in the medication administration record indicated that the facility was awaiting delivery of the medication from the pharmacy, but there was no evidence that the pharmacy or the physician was notified about the missed doses. Additionally, on one of the days, the medication was available but still not administered, and no explanation was documented for this omission. Interviews with staff revealed that the process for ordering and following up on medications was inconsistent. Nursing staff reported that they would typically contact the pharmacy and notify the physician if a medication was unavailable, but there was no documentation to support that these actions were taken in this case. The clinical nurse consultant confirmed that the medication order was present in the resident's profile but was not filled by the pharmacy initially, and the medication was reordered and delivered, yet still not administered as required. The lack of timely communication and documentation contributed to the resident missing multiple doses of a critical medication.