Failure to Administer Prescribed Medications and Notify Provider
Penalty
Summary
Staff failed to administer a resident's heart rhythm and thyroid medications as ordered by the physician. The resident, who had multiple complex diagnoses including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, chronic systolic heart failure, and hypothyroidism, was admitted with orders for specific medications to be given via gastrostomy tube. On two consecutive days, documentation in the Medication Administration Record (MAR) indicated that the amiodarone and levothyroxine doses were not administered, with staff citing medication unavailability and other reasons. Despite these missed doses, there was no evidence in the progress notes that the physician was notified about the unavailability or omission of the medications. Interviews with nursing staff revealed confusion regarding responsibility for medication administration, particularly due to the resident's preference for female caregivers. One nurse stated he did not administer the medications or feedings and was unsure if another nurse had done so, while another nurse confirmed administering a feeding and medication but was uncertain about the earlier scheduled feeding. The Director of Nursing confirmed that staff are expected to notify the provider if medications are not available or not administered, and to document all provider contact in the medical record. However, documentation and communication protocols were not followed, as the provider was not notified of the missed doses and staff documentation did not accurately reflect who provided care. This failure to follow professional standards of practice resulted in the resident not receiving prescribed medications as ordered.