Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
Facility staff failed to notify the provider when a resident missed doses of two critical medications, amiodarone and levothyroxine, on two consecutive days. Documentation in the Medication Administration Record (MAR) indicated that both medications were not available and were not administered on those dates. However, there was no evidence in the resident's progress notes that the provider was informed of these missed doses, as required by facility policy. The resident involved had multiple significant diagnoses, including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease, chronic systolic heart failure, cardiomegaly, and hypothyroidism. Staff interviews confirmed the medication orders and the expectation to notify the provider if medications are not available or refused, as well as to document all provider contact. Despite these expectations, the required notifications and documentation were not completed for the missed medication doses.