Failure to Administer Scheduled Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) who required hemodialysis received their scheduled morning medications either before or after returning from dialysis. Review of the resident's care plan and physician orders indicated that medication administration times on dialysis days could be adjusted to ensure proper absorption, but the September Medication Administration Record showed that several medications, including amlodipine, Aricept, and duloxetine, were not administered on multiple dialysis days. The facility's policy required staff to be trained in the timing and administration of medications for residents receiving dialysis, but this was not followed in practice. Interviews revealed that the LPN responsible for the resident's care withheld all medications except pain medication on dialysis days and did not administer them when the resident returned. The LPN also stated that she did not seek clarification regarding medication administration for the resident on dialysis days. Additionally, the DON was unaware of the specific order allowing for medication time adjustments and believed all medications were to be held on dialysis days. This lack of communication and adherence to physician orders resulted in the resident missing scheduled doses of essential medications.