Failure to Administer Physician-Ordered Dialysis Medication and Notify Providers
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease (ESRD) and dependent on hemodialysis did not receive a physician-ordered phosphate binder medication as prescribed. The resident, who had multiple comorbidities including chronic anemia, heart failure, and hypertension, was admitted with a care plan that included administration of medications as ordered and monitoring for side effects. Despite this, the facility failed to ensure the resident received Xphozah 30 mg, a phosphate absorption inhibitor, as ordered twice daily. The resident reported that the facility frequently ran out of the medication and did not notify her or the dialysis center to reorder it. Medical record review confirmed the medication had not been administered since a specific date, and there was no documentation that the dialysis center or nephrologist had been informed of the lapse. Further investigation revealed that the medication cart contained an empty bottle of the prescribed medication, and review of the dialysis communication book and forms showed no indication that the need for the medication or its absence had been communicated to the dialysis center or physician. The facility's policies required medications to be administered in a safe and timely manner and for the care plan to reflect the resident's needs related to ESRD and dialysis care. However, these policies were not followed, resulting in the resident not receiving the necessary medication and the responsible parties not being notified of the issue.