Missed Dose of Antihypertensive Due to Medication Out of Stock
Penalty
Summary
A deficiency occurred when a resident with essential hypertension and chronic kidney disease stage 3 did not receive her scheduled morning dose of Metoprolol due to the medication being out of stock. Observation during morning medication administration revealed that the LPN was unable to administer the medication, and confirmed with the pharmacy that it would not be delivered until later that day. The resident's medication order required Metoprolol to be given twice daily, with the morning dose scheduled between 7:00 AM and 9:00 AM. The medication had last been ordered over two weeks prior, and there was no emergency supply available in the facility. Interviews with nursing staff and the DON indicated that the facility's process for reordering medications relied on visual cues from the medication blister pack, specifically when only the blue-marked section remained, which should trigger a reorder approximately eight days before running out. Despite this system, the medication was not reordered in time, resulting in a missed dose. Additionally, there was no documentation in the resident's progress notes regarding the missed dose or notification to the MD, as would be expected per facility protocol.