Failure to Administer Ordered Medication Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure (CHF), atrial fibrillation, and renal insufficiency did not receive twelve doses of Bumex, a diuretic prescribed to manage fluid retention associated with CHF. The medication was ordered to be administered twice daily, but starting with a noon dose, the medication was not available and was not given for several consecutive days. Despite the absence of Bumex, the resident continued to receive potassium chloride as ordered, which is significant because Bumex can cause potassium loss, and the potassium supplement was intended to counteract this effect. Documentation and interviews revealed that multiple staff members, including trained medication assistants (TMAs) and nurses, were aware that the medication was unavailable. Some staff attempted to reorder the medication and notified others, but there was a lack of consistent follow-up and communication. The facility's protocol required staff to check backup storage, contact the pharmacy, notify the clinical coordinator, and inform the physician if a medication was unavailable. However, these steps were not consistently followed, and the physician was not notified of the medication's unavailability until several days after the first missed dose. During the period when the resident was not receiving Bumex, she exhibited symptoms such as shortness of breath, confusion, restlessness, and weight gain. The situation escalated to the point where the resident was hospitalized for acute and chronic CHF and hyperkalemia, with a critical potassium level documented. The failure to administer Bumex as ordered and to follow established protocols for medication unavailability directly contributed to the resident's decline and subsequent hospitalization.