Missed Doses of Antirejection Medications Due to Unavailable Medication and Inadequate Follow-Up
Penalty
Summary
A deficiency occurred when a resident with a history of lung transplant and severe protein calorie malnutrition missed four doses of critical medications, specifically Azathioprine and Tacrolimus, due to the medications not being available in the facility. The resident was admitted after hospitalization and required ongoing antirejection medications as part of their care plan. Medication administration records showed that doses were not given on multiple occasions, with the reason documented as 'Drug/Item unavailable.' Nursing documentation and staff interviews revealed that there was a lack of timely reordering and follow-up with the pharmacy to ensure medication availability. The pharmacy confirmed that refills for certain medications were not requested by the facility in time, and when a STAT delivery was requested, there was no documentation of delivery confirmation or further follow-up when the medication did not arrive. Additionally, there was no documentation in the electronic health record of attempts to obtain the unavailable medications or of physician notification regarding the missed doses at the time they occurred. Staff interviews indicated that communication and documentation protocols were not consistently followed. Nurses and medication aides reported notifying each other about the missing medications, but did not always document their actions or notify the physician as required. The Director of Nursing stated that nurses are expected to persistently follow up with the pharmacy and notify leadership if medications are not delivered, but this did not occur in this instance, resulting in missed doses of essential antirejection medications for the resident.