Failure to Provide Ordered Potassium and Calcium/Vitamin D Supplements Due to Medication Unavailability and Lack of Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of ordered medications for one resident. The resident had multiple diagnoses, including aftercare following joint replacement surgery, radial nerve injury, vascular dementia, morbid obesity, adult failure to thrive, need for assistance with personal care, presence of right artificial hip and left artificial shoulder joints, muscle weakness, and chronic congestive heart failure. Review of the Medication Administration Record (MAR) showed that ordered Potassium Gluconate 550 mg and Calcium + Vitamin D3 600-5 mg–mcg supplements were not administered on multiple documented dates. These MAR entries were marked with a “9” by an LPN, indicating “Other/See Nurse Notes,” but there were no corresponding nurse’s notes explaining why the medications were not given. During interview, the LPN stated that both supplements were unavailable in the facility on the dates they were not administered and reported that she had informed management and ordered additional supplies from the pharmacy, as the medications were over-the-counter. The facility’s policy on Medication Error Identification and Prevention defines omission errors as failure to administer an ordered dose and requires immediate nursing assessment, physician and family notification, documentation in the electronic medical record, and implementation of steps to prevent recurrence. The DON explained that over-the-counter medications are restocked by contacting the contracted pharmacy and that staff are expected to complete medication error paperwork, provide immediate education, notify the physician and family, and document associated notes when a “9” is used on the MAR. The DON stated that a “9” should have associated documentation and that management should be informed, but also reported not being made aware of these specific medication omissions for the resident.
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