Failure to Notify Physician of Missed Medication Administration
Penalty
Summary
The facility failed to notify the physician when a resident was not administered medications as ordered. Medical record review, observation, staff and physician interviews, and review of pharmacy delivery sheets and facility policy revealed that a resident with multiple diagnoses, including dementia, atrial fibrillation, and diabetes, did not receive several prescribed medications on multiple occasions. The medication administration records (MAR) showed blank entries and notations of medications being unavailable, yet there was no documentation that the physician was informed of these missed doses. Further review indicated discrepancies between the medications documented as administered on the MAR and the actual availability of those medications in the facility. The Director of Nursing (DON) confirmed that the MAR reflected administration of medications even when the facility did not have them in stock, and could not explain these discrepancies. Additionally, the DON verified that there was no evidence of physician notification regarding the missed medications, despite facility policy requiring immediate notification for changes in treatment. Interviews with staff revealed a lack of understanding regarding the need to notify the physician about missed medications, with one LPN stating she would only notify the physician if the medication was considered important, but could not define what constituted an important medication. The resident in question experienced an acute change in condition, including altered mental status and abnormal vital signs, and was subsequently transferred to the hospital. The primary care physician confirmed he was not notified of the medication discrepancies.