Failure to Administer Ordered Medication Due to Availability and Communication Issues
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident with diagnoses including bladder cancer, dysphagia, and electrolyte and fluid imbalance. The resident had a physician's order for Phos-NaK, an electrolyte supplement, to be given four times daily. Review of the Medication Administration Record (MAR) showed that, except for one evening dose, all doses were marked as 'other,' indicating they were not administered. Progress notes documented that the medication was 'on order' or that the facility was waiting for the pharmacy to fill it, and multiple notes indicated that the facility's nurse practitioner was aware of the situation. However, interviews with two Certified Nurse Practitioners revealed they were not aware that the resident was missing her ordered medication. Further review showed that the pharmacy had informed nursing staff that Phos-NaK was an over-the-counter medication and should be provided by the facility. The Director of Nursing confirmed that the resident missed several days of the ordered medication. Facility policy required that if three consecutive doses were unavailable, the nurse was to notify the physician and document both the notification and the physician's response, but this was not followed in this case.