Failure to Administer Ordered Pirfenidone Doses as Prescribed
Penalty
Summary
Surveyors identified a deficiency in medication administration when a resident with idiopathic pulmonary fibrosis (IPF) and chronic respiratory failure with hypoxia did not receive the prescribed medication Pirfenidone on three documented occasions. The resident had a physician’s order, dated December 21, 2025, for Pirfenidone 801 mg by mouth every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM. Review of the December 2025 Medication Administration Record (MAR) showed missed doses on December 26 at 2:00 PM, December 27 at 2:00 PM, and December 28 at 10:00 PM. The facility’s policy and procedure for Medication Administration required that medications be administered in accordance with written physician orders. During interviews, LVN 1 acknowledged that he did not administer the resident’s Pirfenidone on December 26 and 27 at 2:00 PM because he could not find the medication in the cart and did not check with the previous nurse to determine if the medication was available. LVN 2 stated she did not administer the Pirfenidone dose on December 28 at 10:00 PM because she was unable to locate the medication in the cart. The DON stated that her expectation was that communication between nurses should occur during shift changes and acknowledged that this communication did not occur, resulting in the resident not receiving the medication as prescribed. The facility failed to ensure that Pirfenidone was administered according to the physician’s orders and its own medication administration policy.
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