Failure to Administer Medications as Ordered and Maintain Professional Standards
Penalty
Summary
Two residents did not receive medications as ordered, resulting in a failure to provide services that met professional standards of quality. One resident, a male with multiple complex diagnoses including metabolic encephalopathy, hyperlipidemia, chronic inflammatory demyelinating polyneuritis, lumbar fracture, and muscle weakness, was admitted and subsequently discharged on the same day. He was dependent on assistance for activities and had physician orders for several critical medications, including anticoagulants and anticonvulsants. On the day of admission, he did not receive nine scheduled medications because the facility did not have them available. The nurse documented that the medications had not arrived from the pharmacy and that the earliest delivery would be after the resident's planned discharge. Communication between medication aides, nurses, and facility leadership revealed confusion and miscommunication regarding the process for obtaining medications from the emergency kit and timely notification of missing medications. The nurse practitioner was not informed of the missed doses at the time, and the resident and his family chose to leave the facility due to the lack of medication availability. Another resident with end-stage kidney disease, anemia, history of kidney cancer, and dependence on hemodialysis did not receive a prescribed phosphate binder medication, Sevelamer Carbonate, for a total of 41 missed doses over several weeks. The medication was ordered to be given three times daily with meals, but was not administered on multiple occasions due to unavailability. Nursing staff reported calling the pharmacy and dialysis center, but there was confusion regarding responsibility for ordering the medication, especially after a change in CMS rules that shifted responsibility to the dialysis center. The assistant director of nursing was unaware of the missed doses until reviewing the medication administration record, and the director of nursing later approved a supply to be delivered at the facility's expense. Documentation errors were also noted, with some doses marked as given in error. The resident's physician was aware of the medication's unavailability within a few days but did not consider the missed doses a risk to the resident's health. Facility policy required timely administration of medications and specific procedures for handling unavailable medications, including physician and family notification, completion of medication error reports, and monitoring for adverse reactions. In both cases, the facility did not follow these procedures, resulting in residents not receiving medications as ordered and a lack of timely communication and documentation regarding the missed doses.