Missed Antihypertensive Medication Doses Due to Untimely Refill Request
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received all scheduled doses of prazosin hydrochloride, a medication prescribed for hypertensive heart disease. The resident was admitted with a diagnosis of hypertensive heart disease without heart failure and had intact cognition. Physician orders indicated the resident was to receive prazosin hydrochloride 5 mg at bedtime and amlodipine 5 mg daily. While the resident consistently received amlodipine, the last dose of prazosin hydrochloride was administered on 06/07/25, after which three consecutive doses were missed. The missed doses resulted from a failure to request a timely refill from the pharmacy before the medication supply was depleted. Nurse #3 discovered the medication was unavailable on the cart and noted a refill request had been made, but did not follow up with the pharmacy or notify the DON. The MAR reflected that the medication was not administered and was held for three days. The pharmacy records showed the order was on hold pending clarification and receipt of a new prescription from the NP, which was not received until 06/11/25, at which point the medication was dispensed and administration resumed. During this period, the resident's blood pressure readings increased, and the resident reported not receiving the medication to both nursing staff and the NP. Interviews with staff confirmed that the expected protocol was to reorder medications 5-7 days before depletion and to notify the DON if a medication was unavailable. However, these steps were not followed, resulting in the resident missing three scheduled doses of prazosin hydrochloride.