Failure to Administer Oral Chemotherapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including aphasia, esophageal cancer, and vascular dementia did not receive their prescribed oral chemotherapy medication, capecitabine, for approximately 30 days. The resident was admitted with orders for capecitabine to be administered in cycles, but a review of the clinical record revealed a gap in active orders for the medication from early July to early August. During this period, the medication was not administered, as confirmed by the Medication Administration Record, which showed no doses given between the evening of July 4th and August 4th. There was no documentation or physician order indicating that the medication should have been stopped, and the resident’s family reported that the oncologist was able to determine the medication had not been provided during a follow-up appointment. Interviews with facility staff, including the DON and ADON, revealed that the process for reviewing medication changes after outside appointments relies on paperwork being returned and reviewed by the receiving nurse. However, no documentation was found to support discontinuation of the chemotherapy, and the facility could not provide medication error reports for the resident. The gap in medication administration was attributed in part to the termination of the nurse practitioner who had written the previous order, but no further explanation was provided for the lapse in care.