Failure to Notify Physician of Missed Medications Due to Resident Absence
Penalty
Summary
The facility failed to immediately notify a resident's physician or nurse practitioner when multiple doses of prescribed medications were missed due to the resident being out on pass. The resident, who had diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have missed several doses of critical medications such as aspirin, divalproex, doxepin, haloperidol, folic acid, multivitamin, and metoprolol over several days when she was away from the facility. Medication Administration Records (MAR) indicated these missed doses, but there was no documentation that the physician or nurse practitioner was notified upon the resident's return. Interviews with nursing staff revealed inconsistent practices regarding notification of missed medications. Some staff stated that they would notify the nurse practitioner or physician depending on the number of missed doses, while others indicated that the expectation was to always notify and document such events in the progress notes. However, review of the resident's progress notes confirmed that no such notifications or documentation occurred for the missed medications during the relevant period. The nurse practitioner also confirmed that he was not informed about the missed doses and emphasized the importance of being notified to provide appropriate recommendations. Further review showed that the facility's policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications. Despite this, there was no evidence of staff training on this requirement during the period in question, and staff interviews indicated a lack of clarity and consistency in following the policy. The deficiency was identified through record review and staff interviews, which confirmed the failure to notify the physician or nurse practitioner as required.