Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to notify a resident's physician when ordered medications were not available for administration. A review of the medical record for a resident admitted with diagnoses including hypertension, hyperlipidemia, anxiety disorder, acid reflux, and uncontrolled diabetes mellitus type II showed that several prescribed medications—gabapentin, Pepcid, rosuvastatin, and extra strength Tylenol—were not administered as ordered due to unavailability. Documentation on the Medication Administration Record (MAR) and progress notes indicated that the medications were not given, but there was no evidence that the physician was notified of the missed doses. Interviews with nursing staff confirmed that the physician should have been notified when medications could not be administered, but this was not done. The Director of Nursing also stated that it was the responsibility of nursing staff to notify the physician and document such notifications, but was unaware of the missed medications. The resident missed a total of seven doses across multiple medications, and the lack of physician notification was not documented in the progress notes as required by facility policy.