Failure to Notify Physician of Unavailable Medications
Penalty
Summary
The facility failed to notify a resident's physician when several critical medications—methimazole, albuterol sulfate, and ipratropium bromide—were unavailable for administration upon the resident's admission. The resident had multiple significant diagnoses, including fractures, acute respiratory failure with hypoxia, and anxiety disorder, and was determined to lack capacity for decision-making. Medication orders for these drugs were in place, but the medications were not available at the scheduled administration times. Licensed nursing staff documented the unavailability of the medications in the resident's medical record and followed up with the pharmacy, which indicated the medications would be delivered the following day. However, the physician was not notified of the missed doses. The LVN involved stated that he reported the issue to RN supervisors and documented the situation but did not contact the physician because he did not receive instructions to do so from the supervisors. Further review and interviews confirmed there was no documented evidence that the physician was informed about the medication unavailability. Facility policy required prompt notification of the physician and resident representative regarding changes in the resident's condition or status, including when medications are not available. The Assistant Director of Nursing confirmed that the physician should have been notified to determine an alternative plan.