Failure to Notify Provider and Pharmacy of Missed Medication Administration
Penalty
Summary
A deficiency occurred when nursing staff failed to notify the provider and pharmacy regarding the unavailability and non-administration of a newly ordered medication for a resident with a history of constipation, failure to thrive, and aphasia following a stroke. The resident was prescribed hydrocortisone acetate suppositories for rectal bleeding, but a drug interaction alert with aspirin was triggered by the pharmacy. The pharmacy contacted the facility for clarification, faxed a form for completion, and did not send the medication due to lack of response. Despite this, the medication was not administered for several scheduled doses, and there was no documentation that the provider was notified of the missed doses or the medication's unavailability during this period. Nursing staff, including charge nurses and supervisors, did not follow up with the pharmacy or notify the provider each time the medication was not available or administered. Some staff believed the issue had already been reported, while others documented the missed administration in a provider book but did not ensure direct communication. Interviews revealed that staff signed off on medication administration in error and acknowledged they should have contacted the pharmacy and provider but did not do so. Nursing supervisors were also not informed of the ongoing issue and stated they would have assisted if notified. The facility's policy required nursing staff to notify the physician or prescriber for any held medications or suspected adverse drug reactions, but this was not followed. As a result, the resident experienced ongoing rectal bleeding and severe constipation, ultimately requiring transfer to the emergency department for evaluation and urgent intervention. The lack of timely communication and follow-up regarding the medication order and administration led to the identified deficiency.