Failure to Notify Responsible Party of Unavailable Medication
Penalty
Summary
Facility staff failed to notify the responsible party when a physician-ordered medication, Daptomycin, was not available for administration to a resident with a left foot infection and gangrene. The resident was alert with some forgetfulness, and the medication was ordered to be given intravenously every other day for 23 days. On the scheduled administration date, the medication was not available, and the nurse's note indicated that the pharmacy would deliver it during the next run and that the nurse practitioner was aware. However, there was no documentation that the responsible party was informed of the missed dose. Staff interviews confirmed that the facility's procedure requires notifying the responsible party when a medication is unavailable, and this notification should be documented in the progress notes. Review of the clinical record and facility documentation did not show evidence that the responsible party was notified as required. The facility's policy also mandates immediate notification of the patient's representative when there is a need to alter treatment significantly, such as when a medication is not available.