Failure to Document Unavailable Medications and Notify Physicians of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to properly document unavailable medications and to notify physicians when ordered medications were not administered as prescribed. For one resident with a history of urinary tract infections and chronic kidney disease, physician orders directed Bactrim DS to be given twice daily for multiple 14‑day courses beginning in mid‑December. The MAR showed an initial dose given, followed by blank or coded entries (such as “9 – Other/See Nurse Notes”) for multiple scheduled doses. Progress Notes for some of these dates documented that Bactrim was “awaiting delivery,” but there were also instances where a “9” code appeared on the MAR without any corresponding explanatory note in the record. Across several consecutive order periods for this same resident, the facility repeatedly entered new Bactrim DS orders with new start dates while multiple morning doses were not administered and marked with code 9 on the MAR. For some of these missed doses, the Progress Notes indicated the medication was still awaiting delivery from the pharmacy, and a later note documented that the pharmacy was contacted and that Bactrim was to be sent stat with use of an automated dispensing system supply until delivery. However, review of the medical record from mid‑December through the end of the month did not show documentation that the physician was notified when Bactrim DS was not administered as ordered during these periods. For another resident admitted with diagnoses including primary generalized osteoarthritis, cerebellar ataxia, pneumonia, and generalized muscle weakness, physician orders directed daily intramuscular cyanocobalamin (vitamin B‑12) injections for neuropathy over seven days. The MAR documented codes of “12 = Not Applicable” on two days and “9 = Other/See Nurse Note” on another day for the B‑12 injections, but the Progress Notes contained no documentation explaining these codes or the reasons the injections were not given. This resident reported feeling more fatigued than usual and believed she had not received all of her B‑12 injections, and the DON stated that not all doses had arrived from the pharmacy. Review of this resident’s record for the relevant period showed no documentation that the physician was notified when the B‑12 injections were not administered as ordered, despite facility policies requiring reporting and documentation of medication issues.
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