Failure to Provide Ordered Medications and Notify Physician/Pharmacy
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered by physicians for two of four residents reviewed. For one resident with hyperparathyroidism, Cinacalcet 30 mg daily was ordered upon admission, but the medication was unavailable and not administered for several days. The clinical record did not contain documentation that the physician or pharmacy was notified about the unavailability of the medication. An LPN stated that if a medication is not available, it should be obtained from the emergency drug kit or the pharmacy should be contacted, and the physician should be notified if the medication remains unavailable. Another resident with diagnoses including hypertension and indigestion had orders for Metoprolol Succinate 25 mg extended release and Aluminum hydroxide/magnesium hydroxide/simethicone. Both medications were not administered for several days due to unavailability, and there was no documentation in the clinical record that the physician or pharmacy was notified. The facility's policy requires nurses to contact the pharmacy and physician if medications are unavailable, but this procedure was not followed in these cases.