Failure to Administer Phosphate Binder with Meals as Ordered
Penalty
Summary
A deficiency occurred when a medication aide (MA-B) failed to administer Sevelamer, a phosphate binder prescribed to control high phosphorus levels in a resident with end stage renal disease (ESRD) on dialysis, according to the pharmacy label instructions. The medication was ordered to be given with meals, but MA-B administered three tablets of Sevelamer to the resident without food during a morning medication pass. The medication administration record (MAR) and pharmacy label both specified that the medication should be taken with meals, yet this instruction was not followed. The resident involved was a male with a history of bilateral shin fractures, ESRD requiring dialysis, osteoarthritis, anxiety, and dependence on renal dialysis. At the time of the incident, the resident was observed with dry skin and was seen scratching his body, and he confirmed that he typically takes Sevelamer with meals. The nurse in charge was unaware that the medication had been given without food, and facility policy required verification of medication orders and adherence to label instructions. The failure to administer the medication as ordered constituted a lapse in pharmaceutical services for the resident.