Delayed Physician Notification of Potential Medication Ingestion
Penalty
Summary
The facility failed to promptly notify a resident's physician of an incident involving the potential ingestion of medication, which could have resulted in a negative outcome. The facility's policy requires immediate notification of the resident, their attending physician, and a representative in the event of changes in the resident's condition or status. However, in the case of a resident with a history of metabolic encephalopathy, anxiety disorder, depression, and low back pain, the physician was not notified until approximately eight hours after the incident occurred. The incident involved the resident being found with a bag of pills, which he claimed were candy, and taking an unknown amount of them. The pills were later identified as 500 mg Tylenol. Despite the potential risk of Tylenol toxicity, the resident's physician was not informed until the following morning, after the night shift had monitored the resident for symptoms of toxicity. The delay in notification was due to the night shift nurses not contacting the physician immediately after the incident. The deficiency was further highlighted by the fact that when the physician was finally informed, he ordered the resident to be sent to the emergency department for evaluation. The facility's Nursing Home Administrator and Director of Nursing acknowledged the delay but justified it by stating that the resident showed no signs of toxicity and that the facility's policy allowed for a 24-hour notification window. However, the staff involved in the morning shift felt that the physician should have been notified immediately after the incident occurred.
Plan Of Correction
1. The physician was notified of the incident for resident 44. 2. An initial audit of residents who have had incidents with potential for negative outcomes was completed to ensure the physician was notified. 3. Nursing staff were educated on the need to notify physicians timely of incidents with potential for negative outcomes. 4. Five audits of incidents for MD notification will be audited weekly for 4 weeks, then monthly for 2 months to ensure compliance by DON or designee. Results of these audits will be presented to the QAA committee for review. 5. The facility will be in substantial compliance by 1/7/25.