Failure to Administer Prescribed Antiretroviral Medication
Penalty
Summary
A significant medication error occurred when a resident with HIV did not receive their prescribed antiretroviral medication, Biktarvy, for several consecutive days. The resident was admitted with a hospital-supplied bottle of Biktarvy, but the facility staff were unsure of the quantity provided. Once the initial supply was exhausted, the facility was unable to obtain a refill due to insurance denial and lack of timely payment approval. Multiple staff members, including nurses, the Medical Director, the ADON, and the facility pharmacist, were aware of the medication lapse, but the issue persisted for several days. Documentation on the Medication Administration Record (MAR) showed that Biktarvy was not administered on multiple days, with progress notes indicating the medication was unavailable. Some staff documented administration of the medication when it had not actually been given, and others noted the medication was not on the cart. The facility pharmacy could not dispense the medication until insurance approval was obtained, and even after delivery, there was a delay in administration as the medication was not promptly placed on the medication cart. Interviews with staff confirmed that the medication was not available or administered as ordered during this period. The resident's medical history included HIV with an uncontrolled viral load and a low CD4 count, requiring strict adherence to antiretroviral therapy. The lapse in medication administration was known to several staff members, including the Medical Director, ADON, and pharmacist, but no effective action was taken to ensure the resident received the medication as prescribed. The infectious disease clinic provider was unable to determine the clinical consequences of the missed doses without recent laboratory testing, but the interruption in therapy was confirmed by multiple sources.