Failure to Provide and Administer HIV Medication as Ordered
Penalty
Summary
The facility failed to ensure that a necessary medication, Biktarvy, used to treat HIV, was available and administered as ordered by the physician for a resident over six consecutive days. The resident was admitted with a diagnosis of HIV and had an active physician order for daily administration of Biktarvy. Review of the Medication Administration Record (MAR) showed that the medication was not administered on six specific dates, with incomplete documentation regarding the reason for omission on most of those days. Nursing progress notes only documented that the pharmacy had been contacted for a refill on the first day of omission, with no further explanation for the subsequent missed doses. During interviews, the resident expressed concern about not receiving the medication, reporting that staff informed him it was not in stock and expressing worry about the impact on his health. The resident also reported experiencing diarrhea and concern about infection, as well as uncertainty about when he would see his physician for a prescription refill. An LVN confirmed that the medication was not administered due to lack of supply and stated that the facility protocol would be to notify the physician and arrange for an appointment to ensure continued access to the medication. The LVN also noted that the turnaround time for obtaining the medication from the pharmacy is typically one to two days, emphasizing the importance of timely refills to prevent treatment interruption. The Director of Nursing verified the omission of the medication and acknowledged that the omissions should have been documented and explained by licensed nurses. The DON stated that it was the facility's responsibility to ensure medications are available for each resident and confirmed that the facility failed to have Biktarvy available for the resident on the dates in question. Review of the facility's pharmacy services policy indicated that staff should be educated on pharmacy services, and that drug regimens and medication distribution errors should be reviewed and updated regularly.