Failure to Administer Ordered Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident receiving dialysis care. The resident, who had end-stage kidney disease, diabetes, and high blood pressure, had medication orders for hydralazine and calcium acetate to be given three times daily. On multiple occasions, the resident did not receive their morning doses of these medications on days they attended dialysis, as indicated by the medication administration record, which noted the resident was absent from the facility. There was no documentation that the provider was notified about the missed doses, and no alternative arrangements were made to administer the medications as ordered. Interviews with staff revealed that medications were not sent with the resident to dialysis, and the resident would miss the morning doses if they returned too late. Staff acknowledged that no discussions had occurred with the provider to adjust medication administration times or orders. The resident reported leaving the facility early for dialysis without breakfast and feeling hungry and tired upon return. Nursing leadership stated that they expected nurses to communicate with providers when medications were missed, but this did not occur in this case.