Failure to Notify Physician of Missed Medication Administration
Penalty
Summary
The facility failed to ensure timely physician notification when residents did not receive prescribed medications as ordered. For one resident with a history of left below the knee amputation, diabetes, hypertension, pressure ulcers, and heart failure, an IV antibiotic (Flagyl) was ordered for a wound infection but was not available and never administered. There was no documentation that the physician was notified of the missed doses, and interviews confirmed that the physician was not informed until several days later. The resident's record also lacked evidence of appropriate documentation regarding the missed medication and physician notification. In another case, a resident with Alzheimer's, diabetes, and COVID-19 was prescribed Paxlovid for COVID-19 treatment, but only received 3 out of 10 scheduled doses due to the medication not arriving. The record did not show that the physician was notified about the missed doses, and facility leadership confirmed that the nurse should have notified the physician and documented this in the record. The facility's policy required physician notification when there was a need to alter treatment, but this was not followed in these instances.