Failure to Notify Physician and Administer Prescribed Blood Pressure Medication
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of hypertension did not receive a prescribed blood pressure medication, candesartan-hydrochlorothiazide, for four consecutive days following admission. The medication was not available on the medication cart or in the backup medication dispensing machine, and although it was ordered from the pharmacy, there was no follow-up or documentation indicating that the medication had been received or administered during this period. Progress notes and the Medication Administration Record confirmed the medication was not given on four specific days, and there was no documentation that the attending physician was notified of the unavailability of the medication. Interviews with the resident and the Director of Nursing (DON) revealed that the resident expressed concern about not receiving the medication and that the DON was unaware of the missed doses until after the fact. The DON stated that facility protocol required contacting the pharmacy and notifying the medical provider for further instructions or alternative orders when a medication was unavailable, but there was no evidence this occurred. The pharmacy technician also failed to communicate with the facility regarding the delay. Documentation from the physician and provider progress notes did not mention the medication's unavailability, and there was no indication that alternative measures were considered during the four-day lapse.