Failure to Notify Physician and Responsible Party When Cardiac and Diuretic Medications Were Unavailable
Penalty
Summary
Facility staff failed to notify the physician and responsible party when ordered medications were not available and therefore not administered to a resident. For Resident #24, a physician order dated 1/21/2026 directed administration of Metoprolol Succinate ER 25 mg by mouth once daily for heart failure. The January 2026 MAR reflected this order, and on 1/21/2026 at the 9:00 a.m. dose, the nurse documented a "9," indicating "Other/See Progress Note." The corresponding progress note at 11:53 a.m. on 1/21/2026 stated "Awaiting pharmacy supply," indicating the medication was not available for administration. Resident #24 also had a physician order dated 1/17/2026 for Bumetanide 0.5 mg by mouth once daily as a diuretic, which was likewise documented on the January 2026 MAR. On 1/21/2026 for the 9:00 a.m. dose, a "9" was again documented, with the progress note at 11:53 a.m. stating "Awaiting pharmacy supply." Interviews with an LPN and the DON confirmed that when a medication is not in the cart and not in the backup pharmacy system, the nurse is expected to contact the pharmacy, notify the physician and responsible party that the medication is not available, and document this in the medical record. The facility reported having no policy on notification of the physician or responsible party, and the record contained no documentation that the physician or responsible party were notified when these medications were not administered due to lack of pharmacy supply.
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