Failure to Administer Physician-Ordered Calcium Carbonate Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that two residents received their prescribed calcium carbonate oral tablets as ordered by their physicians. For both residents, physician orders specified daily or twice-daily administration of calcium carbonate for conditions such as osteoporosis and supplementation. However, medication administration records and interviews revealed that the medication was not available in the medication cart on multiple occasions, resulting in missed doses over the course of a week for each resident. For the first resident, who had diagnoses including chronic kidney disease, type 2 diabetes mellitus, and muscle weakness, the calcium carbonate was not administered on several specified dates. Although the attending physician was reportedly notified and ordered the medication to be held until available, there was no documented evidence of this notification or order in the resident's records. The facility's own policy required medications to be administered as ordered and for any administration to be documented immediately on the medication administration record (MAR), but this was not followed. Similarly, the second resident, with diagnoses including acute kidney failure, type 2 diabetes mellitus, and gastro-esophageal reflux disease, did not receive the ordered calcium carbonate on multiple dates due to unavailability. Again, there was no documented evidence that the physician was notified or that an order to hold the medication was obtained. The facility's policy and procedure for medication administration, which mandates adherence to physician orders and proper documentation, was not followed in these instances.