Failure to Administer Ordered Antihypertensive Due to Lack of Follow-Up on Missing Medication
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed antihypertensive medication as ordered for one resident. The resident, who had diagnoses including hypertension and type 2 diabetes mellitus, reported in an interview that he did not receive his medications as ordered. Review of the Medication Administration Record for a specified period showed an active order for clonidine HCl 0.5 mg to be given orally twice daily, yet the record indicated the resident did not receive any doses during that entire period, with the reason documented as awaiting delivery from the pharmacy. Nursing notes for the same timeframe contained no documentation that the pharmacy or the nurse practitioner (NP) was notified that the resident had not received the ordered clonidine due to pharmacy delay. In interviews, an RN stated that when a medication has not been delivered, the nurse should call the pharmacy for updates and keep the resident and NP informed, and the DON stated that the pharmacy reported receiving no additional communication from the facility regarding this medication. The DON also described a lack of communication on the day the NP was to see the resident, resulting in the missed clonidine not being addressed. The facility’s medication administration policy specified timing parameters for giving medications but did not include a protocol for handling missing medications from the pharmacy.
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