Failure to Notify Physician of Resident's Refusal of Psychotropic Medication
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician after a resident refused a scheduled psychotropic medication. The resident, who had diagnoses including Schizoaffective Disorder, Paranoid Schizophrenia, and Obsessive-Compulsive Disorder, was assessed as having intact cognition and a history of refusing care, including medications. The resident's care plan required staff to carry out the prescribed medication regimen and report any changes or complications to the physician. On the scheduled date, the resident refused a long-acting injectable psychiatric medication, as documented in the Medication Administration Record. However, there was no documentation in the progress notes that the physician was notified of this refusal. Staff interviews revealed that the LPN on duty was unsure if the resident received the scheduled medication and admitted to not documenting or notifying anyone about the refusal. The psychiatric nurse practitioner confirmed that they were not informed of the missed dose, which could have contributed to the resident's subsequent behavioral decline. The DON stated that nurses are expected to re-offer the medication and notify the physician if refusal persists, as well as document the refusal in the resident's chart. The absence of documentation and physician notification following the medication refusal constituted the deficiency.