Failure to Administer Ordered Medications and Notify Physician
Penalty
Summary
Nursing staff failed to administer prescribed medications to a resident as required by professional standards and facility policy. During a medication administration observation, an LPN did not provide the resident with Icar-C and Cyanocobalamin tablets because the medications were not available in the medication cart and were still on order. The LPN marked the medications as 'on order' in the electronic Medication Administration Record (eMAR) but did not notify the physician or the resident's representative about the missed doses, nor did she attempt to obtain the medications from an alternate pharmacy source. Interviews with the LPN, RN, DON, and Administrator confirmed that the LPN did not follow the facility's policy, which requires notification and efforts to secure medications from other sources when they are unavailable. The resident involved had a history of chronic kidney disease and a moderately impaired cognitive status, as indicated by a BIMS score of 10. The failure to administer the ordered medications and the lack of appropriate notifications or attempts to obtain the medications from another pharmacy source were directly observed and confirmed through interviews and record reviews. Facility policy required that medications be administered as prescribed and that appropriate steps be taken when medications are unavailable, which was not followed in this instance.