Failure to Timely Notify Physician and Responsible Party of Medication and Diagnostic Test Issues
Penalty
Summary
The facility failed to notify the physician, Medical Director, or responsible party in a timely manner regarding two separate incidents involving two residents. In the first case, a resident was prescribed Benadryl anti-itch cream, but the medication was not available from the pharmacy for three days. Documentation showed that staff were aware of the unavailability and that the medication was not administered as ordered, but there was no timely notification to the physician or a change in medication until three days after the initial order. The resident's family only became aware of the issue through the resident, not from facility staff. In the second case, a resident experienced a change in condition, prompting new orders for diagnostic urine testing via in-and-out catheterization every shift for two days. The health record did not show that attempts were made to obtain the urine sample on one of the days, nor was there documentation that the physician or responsible party was notified of the missed collection and incomplete test. The lack of notification persisted until the resident was transferred to the hospital, at which point the physician and family were informed. The DON confirmed that both the physician and responsible party should have been notified of the inability to obtain the urine specimen.