Failure to Notify Physician and Document Change of Condition After Missed Medications
Penalty
Summary
The facility failed to notify physicians when four residents did not receive their scheduled 9:00 a.m. medications on a specific date. Licensed nurses did not document a change of condition (COC) or inform the residents' physicians about the missed doses, as required by facility policy. This lack of notification and documentation was confirmed through interviews with nursing staff, who acknowledged that such actions should have been taken to ensure proper monitoring and care. The residents involved had significant medical histories, including conditions such as cerebral infarction, atrial fibrillation, hypertension, pancytopenia, malignant neoplasm, thrombocytopenia, diabetes mellitus, peripheral vascular disease, cerebrovascular disease, myocardial infarction, and chronic obstructive pulmonary disease. Each resident's medication administration record indicated that the scheduled morning medications were not administered, and there was no evidence of physician notification or COC documentation in the records. Interviews with staff, including LVNs, the facility pharmacist, and the Director of Nursing, confirmed that the standard procedure when medications are missed is to notify the physician and document the event as a COC. The facility's job descriptions and policies also require reporting of medication errors and changes in condition to the appropriate parties. However, these procedures were not followed in this instance, resulting in a delay of evaluation, care, treatment, and monitoring for the affected residents.