Failure to Administer Medication as Ordered with Required Food
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as ordered for a resident with end stage renal disease and type 2 diabetes mellitus with chronic kidney disease. Specifically, the medication Sevelamer Carbonate, prescribed to be taken with meals to control phosphorus levels, was administered by a medication aide without food, contrary to the physician's order and the instructions on the medication container. During observation, the medication aide gave the resident two tablets of Sevelamer Carbonate in the resident's room where no food or snacks were present. The resident confirmed that he had eaten lunch much earlier and would not have dinner until later, and the aide did not inquire about the availability of snacks or offer food at the time of administration. The medication administration record showed the medication was documented as given at that time, and the aide later acknowledged not following the special instructions due to being observed during the process. Interviews with the facility pharmacist, hemodialysis nurse, nurse practitioner, and director of nursing confirmed that Sevelamer Carbonate requires administration with food for proper absorption, as indicated by the physician's order and medication label. The facility's policy also requires medications to be administered as prescribed, including any special instructions. The failure to administer the medication with food constituted a deviation from both the physician's order and facility policy.