Failure to Notify Providers of Unavailable Medication and RP of New Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify medical providers when an ordered medication was unavailable for administration to a resident with diabetes mellitus type 2. The cognitively intact resident had a physician’s order for weekly subcutaneous Ozempic for DM II and weight loss. Pharmacy records showed the medication had been delivered and signed for, but the Medication Administration Records (MARs) for October, November, and December documented multiple dates when nurses did not administer the Ozempic because it was not available. On at least three separate dates, different nurses documented the medication as unavailable yet did not notify the resident’s physician or other medical provider, and they were unable to explain why they had not done so. Facility leadership, including the ADON, DON, NP, Medical Director, and Administrator, all stated that a provider should have been notified immediately when the medication was not available so that alternative medications or orders could be obtained. The deficiency also includes the facility’s failure to notify a resident’s responsible party (RP) when a new deep tissue injury (DTI) developed on the resident’s right heel. The resident was severely cognitively impaired and had an existing unhealed pressure ulcer. A wound progress note documented that care was reestablished due to a new right heel DTI, with measurements and a treatment plan that included daily skin prep and offloading pressure, and indicated the plan was discussed with staff and the resident. Subsequent physician orders were entered for skin prep and Prevalon boots to offload pressure. However, there was no documentation in the medical record that the RP was notified of the new DTI. Interviews and record review confirmed the lack of required notifications. The RP later reported that she had not been informed of the right heel DTI and only became aware of the pressure wound when the resident was transferred to the hospital months later. The ADON and DON, after reviewing the medical record, confirmed there was no documentation of RP notification regarding the new DTI. The interim Administrator stated she had been unaware that RPs were not being informed of new skin concerns and acknowledged that RPs should be notified after the physician is called and treatment orders are obtained, with such notification documented in the record.
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