Failure to Notify Physician of Unavailable Medications
Penalty
Summary
Facility staff failed to notify physicians when ordered medications were unavailable for administration to three residents. For one resident, multiple medications including insulin, antihypertensives, and others were not administered as ordered on a specific evening, and there was no evidence in the clinical record that the physician was informed of the missed doses. The resident had recently arrived, had multiple chronic conditions, and was scheduled for hemodialysis, but the lack of medication administration and physician notification was documented in the medication administration record and progress notes. Another resident did not receive several prescribed medications, including an antifungal, an antipsychotic, and an inhaled medication, on two consecutive days due to unavailability. The electronic medication administration record and nurse's notes indicated the medications were pending delivery or unavailable, but there was no documentation that the physician was notified of the missed doses. The resident had diagnoses including bipolar disorder, pulmonary hypertension, and muscle weakness. A third resident did not receive prescribed Gabapentin for neuropathy over multiple scheduled doses, as the medication was on order from the pharmacy. Progress notes indicated the medication was not available, but again, there was no evidence that the physician or nurse practitioner was notified. Interviews with administrative staff confirmed that the facility's policy requires physician notification when medications are unavailable, but this was not documented in these cases.