Failure to Administer Medications as Ordered and Notify Physician of Missed Doses
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and did not document physician notification for missed medications for a resident with end stage renal disease (ESRD) who was dependent on renal dialysis. Review of the resident's Medication Administration Record (MAR) for June and July 2025 revealed multiple missed doses, including 31 missed doses of Lactobacillus, five missed doses of house protein, and single missed doses of atorvastatin calcium, ferrous sulfate, and a multivitamin. The MAR indicated these medications were marked as refused, but the resident stated she sometimes did not receive her medications because she was at dialysis and denied refusing them. Interviews with nursing staff and the Director of Nursing confirmed that a refusal should be documented, the physician should be notified, and a progress note should be entered. However, there was no documentation of physician notification for the missed medications. Facility policy requires medications to be administered as prescribed, refusals to be followed by physician notification, and medication errors to be documented and reviewed. These procedures were not followed in this case, resulting in the deficiency.