Failure to Timely Notify Provider of Unavailable Medication
Penalty
Summary
Facility staff failed to notify a resident's provider in a timely manner when a prescribed medication, tetrabenazine, became unavailable. The facility's policy requires immediate action and provider notification when a medication cannot be obtained, including obtaining alternative treatment orders or specific monitoring instructions. For one resident with diagnoses including bipolar disorder, schizoaffective disorder, anxiety, and vascular dementia, the medication was not administered from early April through late May, with documentation showing the pharmacy and insurance issues were known by staff. Progress notes indicated awareness of the unavailability, but there was no documentation that the provider was notified until eight days after the last dose was given. The resident was cognitively intact and had active orders for antipsychotic, antianxiety, and anticonvulsant medications. Despite multiple entries in the medical record about the medication's unavailability, there was no evidence that the provider was promptly informed or that alternative orders were sought as required by facility policy. The Assistant Director of Nursing confirmed the delay in provider notification and the absence of documentation regarding the hold order or provider communication during the period the medication was not available.