Failure to Administer Ordered Medications and Notify Physician of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to provide medications as ordered and to ensure appropriate pharmaceutical services for a resident with multiple complex diagnoses, including end stage renal disease on dialysis, type 2 diabetes mellitus, major depressive disorder, opioid dependence, anxiety disorder, and long-term antibiotic use. The resident had intact cognition per a recent MDS assessment. Physician orders included Amitriptyline 50 mg, two tablets at bedtime for depression; Sevelamer Carbonate 800 mg, two tablets before meals for hyperphosphatemia; and Reglan 5 mg by mouth three times a day for nausea. Review of the MAR showed that the mid-day dose of Sevelamer Carbonate was not administered on multiple dates, and there was no documentation explaining the missed doses on some of those days. On two dates, the record indicated the resident was at dialysis when Sevelamer was not given. Reglan was not administered twice on one date, and Amitriptyline was not administered on two separate dates. Progress notes did not document reasons for several missed Sevelamer doses, and there was no evidence that the physician was notified of the missed Sevelamer or Amitriptyline doses. The physician was not notified of the missing Reglan until two days after it was first not administered. Interview with a regional nurse confirmed that Reglan and Amitriptyline were not administered because the facility had run out of these medications, and Sevelamer was not administered because it had not been given before the resident left for dialysis, despite the resident eating lunch at dialysis and not receiving the medication there. The facility’s medication administration policy required medications to be administered in accordance with orders, but the documented omissions and lack of timely physician notification demonstrated that this did not occur for this resident.
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