Failure to Administer Medications as Ordered for Residents on Dialysis
Penalty
Summary
The facility failed to ensure that medications and treatments were administered as ordered for three of four residents reviewed for omitted medication doses. Specifically, residents with diagnoses including end stage renal disease, dependence on dialysis, type 2 diabetes, and essential hypertension did not consistently receive their prescribed medications, particularly on days when they were out of the facility for dialysis. Medication administration records showed multiple missed doses of blood pressure and other essential medications, with documentation often indicating the resident was at dialysis as the reason for omission. In some cases, the medication was not provided to the resident to take with them, and there was no evidence that the physician was notified of the missed doses or that alternative arrangements were made. Interviews with staff revealed that medication administration was not consistently adapted to accommodate residents' dialysis schedules. For example, a nurse stated that he would provide medications to fully oriented residents to take with them, but did not do so for one resident, believing the resident would not remember to take the medication. The nurse also admitted to not notifying the physician or the charge nurse about the missed doses. The Director of Nursing acknowledged that all residents are expected to receive medications as ordered and recognized the need to address the issue, but at the time of the survey, the deficiency persisted. Facility policy required that residents leaving the facility temporarily be provided with necessary medications, but this was not consistently followed. The lack of coordination between medication administration times and residents' dialysis schedules, combined with inadequate communication with physicians regarding missed doses, resulted in multiple missed opportunities for residents to receive essential medications as prescribed.