Failure to Ensure Resident Received Ordered Medications Due to Coordination and Documentation Issues
Penalty
Summary
Facility staff failed to ensure that a resident received all medications as ordered by the physician, resulting in significant medication errors. The resident, who had multiple diagnoses including acute osteomyelitis, end-stage renal disease requiring dialysis, and other chronic conditions, missed several dialysis appointments due to transportation issues related to his height and wheelchair needs. As a result, the resident missed six critical doses of Gentamicin IV, which was to be administered during dialysis sessions. Additionally, there was confusion among staff regarding the provision and administration of Calcium Acetate, a phosphorus binder required with each meal. Documentation showed that the resident did not receive this medication from admission through the end of March and missed 19 doses in April, with the MAR lacking clear records of administration or coordination with the dialysis center. Interviews with facility staff, including the DON, revealed uncertainty about responsibilities for medication administration and documentation, particularly regarding medications provided by the dialysis center. The facility's communication and medication administration records did not adequately track whether the resident received Gentamicin IV or Calcium Acetate as ordered. Laboratory results indicated elevated phosphorus levels, consistent with missed doses of the phosphorus binder. The administrator was informed of these concerns, but no additional information was provided at the time of the survey.