Failure to Administer Ordered Cardiovascular Medication and Notify Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed cardiovascular medication was administered as ordered for one resident. The resident had diagnoses including end stage renal disease with hemodialysis, essential hypertension, and a history of myocardial infarction, and had intact cognition with minimal assistance needs. The care plan included administering medications per physician orders and monitoring cardiovascular status. A physician’s order dated 12/27/25 directed that the resident receive diltiazem extended-release 120 mg orally once daily. Review of the December 2025 MAR showed that this medication was not administered as ordered and was marked as unavailable by the nurse. An electronic MAR note on 12/27/25 at 11:36 A.M. documented that the diltiazem was not given because medications had not yet arrived from the pharmacy. Progress notes showed that the resident was readmitted to the facility on 12/26/25 after hospitalization for altered mental status, and on 12/27/25 at 4:24 P.M. the resident called the police reporting that he had not received his medications. The same note stated that the pharmacy had not delivered that morning, the nurse pulled available medications from the emergency medication bank, and that medications were delivered shortly afterward and the resident was reminded he did receive his medications. However, the pharmacist reported that the pharmacy did not receive the medication orders until 12/27/25 at 4:21 A.M. and that the medications, including diltiazem, were delivered at 3:30 P.M. and signed for by facility staff. A nurse’s note on 12/28/25 at 2:45 A.M. documented that the resident called 911 via cell phone to be transferred to the hospital, with vital signs including blood pressure 154/87. The DON confirmed that the nurse did not notify the physician that the diltiazem had not been administered as ordered and stated she was not aware the medication had been delivered and not given. The facility’s medication administration policy was silent regarding holding medications until arrival from the pharmacy.
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