Failure to Notify Physician and Resident of Missed Medication Dose and Refusal of Weight Monitoring
Penalty
Summary
The facility failed to notify a resident and the resident's physician regarding a missed dose of levothyroxine, a medication prescribed for hypothyroidism. The medication was scheduled to be administered in the morning, but was not available due to a delay in pharmacy delivery. Documentation showed that the dose was not given as scheduled, and there was no evidence that the physician or the resident was informed of the missed dose. Interviews with the Director of Nursing and the Director of Staff Development confirmed that the physician should have been notified and that this was not documented in the clinical record. The resident also stated she was not informed about the missed dose. Additionally, the facility failed to notify the physician when a resident refused body weight monitoring for an extended period of 58 days. Physician orders required weekly weights, but after the last recorded weight, the resident declined further monitoring. There was no documentation of the resident's refusal or of any notification to the physician regarding this ongoing refusal. Staff interviews confirmed that there was no record of the refusals or physician notification in the progress notes or care plans. The facility's policies required prompt notification of the resident, physician, and representative of changes in the resident's condition or status, including refusals of care. Despite these policies, the required notifications and documentation were not completed in both instances involving the missed medication dose and the refusal of weight monitoring.