Failure to Notify Emergency Contact and Physician of Medication Changes and Change in Condition
Penalty
Summary
The facility failed to notify a resident's emergency contact of changes in medication orders and did not inform both the physician and emergency contact of a significant change in the resident's condition. Specifically, the resident, who had a history of urinary tract issues and anxiety disorder, received new and adjusted medication orders for Ativan and pyridium over several days. There was no documentation that the emergency contact was notified of these medication changes. Additionally, when the resident exhibited a notable change in condition, including altered responsiveness, low blood pressure, vomiting, and unresponsiveness to questions, there was no documentation that the physician or emergency contact was notified. Interviews with an LPN confirmed that the notifications were not documented in the electronic medical record, despite facility protocol to notify the physician, DON, and family in such situations.