Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident did not receive prescribed Depo-Provera injections as ordered. Documentation revealed that the resident, who had a history of traumatic brain injury, dementia, depressive disorder, seizures, and other significant medical conditions, missed several scheduled doses of Depo-Provera over multiple months due to the medication not being available. Progress notes indicated that the medication was ordered from the pharmacy when unavailable, but there was no documentation that the physician was notified of missed doses on three specific occasions. Additionally, the facility's own policy required physician notification whenever an order was not followed for any reason, including medication unavailability. The director of nursing confirmed that there was no documentation of physician notification for the missed doses on the identified dates. Medication error reports were only completed for two of the missed doses, with physician notification documented for those instances, but not for the earlier missed doses.