Failure to Notify Physicians When Ordered Medications Were Unavailable
Penalty
Summary
Facility staff failed to notify physicians when ordered medications were not available for three residents, contrary to the facility’s Medication Orders policy requiring nursing to contact the prescriber when delivery of a medication will be delayed or the medication is not or will not be available. For a moderately cognitively impaired resident, the physician had ordered hydrochlorothiazide for hypertension and MiraLAX for constipation; the MAR showed multiple dates in which these medications were marked as not available, and nurse notes for the same period contained no documentation that the physician or pharmacy had been contacted. A cognitively intact resident had multiple ordered medications, including hydrochlorothiazide, cyclobenzaprine, Boost, lemon drops, ferrous gluconate, rosuvastatin, and vitamin B12. The MAR documented several of these medications as not available on multiple dates, yet nurse notes did not show any physician notification. A severely cognitively impaired resident had orders for colestipol, donepezil, Eliquis, potassium chloride, methenamine hippurate, and vitamin C; the MAR documented repeated instances of these medications being unavailable across many days, including Eliquis and potassium chloride, without corresponding documentation in nurse notes that the physician was contacted when the medications were not administered. In interviews, a CMT stated staff would report unavailable medications to the charge nurse, and the ADON and DON stated nurses should contact the physician and pharmacy when medications are not available, indicating this did not occur as required.
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