Failure to Administer Physician-Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, resulting in a significant medication error. Specifically, a resident with multiple diagnoses, including end stage renal disease (ESRD), chronic kidney disease (CKD), and type two diabetes mellitus, had a physician order for Xphozah (tenapanor) 30 mg to be administered orally once daily for ESRD. Review of the medication administration records (MAR) for November and December revealed that the ordered medication was not administered on several specified dates. Interviews and record reviews confirmed that the medication was not given because it was not available in the facility on those dates. The facility's policy requires medications to be administered in accordance with written physician orders, but this was not followed in this instance. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for medication administration, with a facility census of 54.