Failure to Provide Timely and Appropriate Dialysis-Related Medication Administration
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident receiving dialysis. Specifically, the facility did not ensure timely administration of scheduled morning medications on the resident's dialysis days. The resident, who was cognitively intact and had a diagnosis of chronic kidney disease, was transported to an outside dialysis clinic early in the morning and returned in the early afternoon. During this time, the resident received a bagged breakfast before leaving but did not have facility medications sent with them, resulting in morning medications being delayed until after their return from dialysis. Additionally, the facility did not administer Sevelamer, a phosphate binder prescribed to be given with meals, as ordered by the physician. The resident's blood phosphorus levels were elevated, and the Sevelamer dose intended for breakfast was consistently missed on dialysis days because it was not sent with the resident or administered at the appropriate time. The medication administration record inaccurately reflected that medications were given at the scheduled times, even though they were actually administered after the resident returned from dialysis. Interviews with nursing staff, the unit manager, the director of nursing, the registered dietitian, and the nurse practitioner confirmed that the medication administration times were not coordinated with the resident's dialysis schedule. The staff were unaware that the Sevelamer was not being administered with breakfast on dialysis days, and the provider was not informed of the delayed medication administration until after the issue was identified by the surveyor. Facility policies required medications to be administered in a timely manner and as prescribed, but these were not followed for this resident.