Failure to Notify Physician When Medication Not Administered
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident's prescribed medication, enoxaparin sodium, was not administered as ordered. Review of the resident's Order Summary Report showed an active order for enoxaparin sodium to be given daily for ten days. The Medication Administration Record indicated that on one day, the medication was not administered, with a note to see the nurse's note. Progress notes documented that the medication was not available and was pending delivery. During interviews, an LVN confirmed that the medication was unavailable and acknowledged that facility policy required physician notification in such cases, but could not provide documentation that the physician had been notified. The Director of Nursing also confirmed that the physician should have been notified when the medication was not available. Facility policy reviewed stated that the prescriber must be contacted if medication delivery is delayed or unavailable.