Failure to Administer Medications and Notify Physicians per Orders
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including acute myeloblastic leukemia, anemia, chronic kidney disease, and severely impaired cognition, did not receive treatment and care in accordance with physician orders and professional standards of practice. The resident had specific orders for medications such as Epoetin Alfa and Venclexta, as well as regular bloodwork and communication of lab results to the oncologist. Documentation revealed that several doses of these medications were not administered as ordered, and required bloodwork and faxing of results were not completed on multiple occasions. The medication administration records showed missing documentation for certain doses, with codes indicating that the medications were not given. Progress notes from nursing staff indicated that medications were on order but did not confirm administration or provide evidence that the physician was notified of missed doses or unavailable medications. Similarly, there was no documentation that the physician was notified when lab results were not obtained or faxed as required. Interviews with nursing staff and the DON confirmed that the expected process was to notify the physician and document such notifications, but this was not done in these instances. Further interviews with the resident's medical providers, including the medical director and oncologist, confirmed that they were not notified of missed medication doses or unavailable lab results, contrary to their expectations and facility policy. The facility's job descriptions and policies also required prompt notification of physicians regarding missed medications, abnormal labs, or changes in condition, but these procedures were not followed or documented for the resident in question.