Failure to Clarify Medication Orders and Ensure Timely Administration
Penalty
Summary
The facility failed to clarify physician's admitting medication orders for a resident admitted for hospice respite care, who had diagnoses including multiple sclerosis, heart failure, and chronic kidney disease. Upon admission, the resident had active orders for both Farxiga and Jardiance, which are considered potential duplicate therapies for diabetes mellitus. The consultant pharmacist identified this duplication and recommended clarification, but there was no documentation that the physician was notified or that the orders were clarified. The resident received both medications for several days, and facility leadership was unable to provide evidence of physician notification or a clinical rationale for the concurrent use of both drugs. Additionally, the facility did not ensure that another resident received their prescribed medication, acetazolamide, as ordered for diuretic therapy. The medication was not available on multiple occasions, and nursing staff documented the unavailability in the medical record. However, there was no documentation that the attending physician was notified about the missed doses, as required by facility policy. The DON confirmed that the nurse should have contacted the physician and that the medication could have been delivered stat, but this was not done. Both deficiencies were identified through record review, interviews, and policy review. The facility's failure to clarify medication orders and ensure timely administration of prescribed medications, as well as to notify the physician when medications were unavailable, were not in accordance with professional standards of practice and facility policy.