Failure to Notify Physician of Resident's Refusal of Blood Tests
Penalty
Summary
The facility failed to notify a resident's physician when the resident refused ordered blood tests on two separate occasions. The resident, who had diagnoses including metabolic encephalopathy, schizoaffective disorder, and Alzheimer's disease, was severely cognitively impaired and required significant assistance with daily activities. Physician orders were in place for weekly complete blood counts due to Clozapine use and for regular valproic acid level monitoring. Documentation showed that the resident refused blood draws on two dates, but there was no evidence in the medical record that the physician was informed of these refusals. During interviews and record reviews, the Director of Nursing confirmed that the physician was not notified each time the resident refused the blood draws, despite the facility's policy requiring timely notification of changes in a resident's condition to physicians, family, or legal representatives. The facility's policy also required updating the care plan to reflect the resident's current status, but this was not documented in relation to the refusals.