Failure to Administer HIV Medication and Notify Physician and Responsible Party
Penalty
Summary
A resident with a diagnosis of HIV and impaired immunity was admitted to the facility and had a physician order for Triumeq, an antiretroviral medication critical for managing HIV. Upon admission, the resident did not receive Triumeq as ordered for an extended period due to issues with medication availability, insurance authorization, and lack of timely follow-up by facility staff. Documentation shows that the medication was not administered on multiple occasions, with staff marking 'not administered' (NA) on the Medication Administration Record (MAR) but failing to consistently document actions taken to resolve the issue or notify the prescribing Infectious Disease (ID) physician, the resident, or the resident representative (RR) about the missed doses. The facility's policies required staff to notify the physician and document actions taken when a vital medication was not available, but interviews and record reviews revealed that these procedures were not followed. Staff often did not document communication with the physician or RR regarding the medication gap, and there was no evidence that the ID physician was informed in a timely manner about the ongoing lack of medication. The resident's care plan identified the risk of infection due to immune deficiency, but interventions to monitor and report complications were not effectively implemented in relation to the missed medication. The facility also lacked a process to ensure timely follow-up on prior authorizations, resulting in prolonged delays in obtaining the medication. As a result of these failures, the resident missed multiple doses of Triumeq over a period of more than a month, which was confirmed by laboratory results showing a significantly elevated viral load and low CD4 count, indicating the medication was not being administered as required. The ID office and RR were not made aware of the medication gap until after the resident's condition had deteriorated. Interviews with facility staff, pharmacy, and the ID office confirmed that communication and documentation were insufficient, and the facility did not provide evidence of timely notification or adequate follow-up to ensure the resident received the prescribed medication.