Failure to Administer Medication as Ordered Upon Resident Readmission
Penalty
Summary
A resident with multiple complex diagnoses, including infrarenal abdominal aortic aneurysm, acute kidney failure, atherosclerosis of the renal artery, anxiety disorder, congenital renal artery stenosis, and cerebral infarction, was re-admitted to the facility from the hospital. Upon review, it was found that the resident did not receive their prescribed dose of Nifedipine ER 30 mg at bedtime as ordered by the physician. The medication was not available upon the resident's return, and the dose was not administered until the following morning, as confirmed by the resident, their representative, and the physician's note. The Medication Administration Record (MAR) indicated the medication was not provided at the scheduled time, and there was no documentation to confirm the medication was obtained from the stat lock or administered as required. Interviews with facility staff revealed that the expectation was to obtain unavailable medications either from a local pharmacy or from the stat lock if the primary pharmacy could not supply them in time. However, the DON was unable to provide evidence that the medication was accessed from the stat lock or given to the resident. The physician was not notified of the missed dose, and the facility's policy required medications to be administered as ordered and documented in the MAR. The failure to provide the medication as prescribed and to document its administration resulted in the identified deficiency.