Failure to Notify Provider of Multiple Missed Gabapentin Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician/Nurse Practitioner when a resident did not receive multiple prescribed doses of Gabapentin ordered for diabetic polyneuropathy. The resident had diabetes mellitus with diabetic polyneuropathy and a physician’s order for Gabapentin 800 mg by mouth three times daily. Review of the Medication Administration Record showed that several doses over multiple days were marked as not administered. Medication Aide and nursing staff reported that the Gabapentin was not in the medication cart on several shifts, and they documented the missed doses on the MAR. However, they did not notify the provider when the first or subsequent doses were missed, despite facility expectations that the provider be notified immediately when a resident does not receive a prescribed medication. Medication Aide #2 stated she reordered the medication in the electronic system when she found it missing but did not recall whom she informed about the missed dose. Nurse #1 documented the missed doses on two night shifts and assumed the provider was already aware because the medication had also been missed on the first shift, but she did not contact the provider. Medication Aide #1 reported the medication had been missing for at least three days, stated she reordered it and informed Nurse #2, and indicated that as a Medication Aide she would not notify a provider. Nurse #2 acknowledged that she did not notify the Nurse Practitioner or medical provider, believing it was a pharmacy delay. The Unit Manager reported that no staff had informed her of the missing medication, and the Nurse Practitioner confirmed she was unaware of the missed doses and stated the facility should have notified her. The Director of Nursing and Administrator stated that staff were expected to notify the Nurse Practitioner or on-call provider when a resident missed a prescribed medication dose, which did not occur in this case.
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