Failure to Notify Physician of Medication Refusals
Penalty
Summary
The facility failed to follow its own policy and procedures regarding the notification of a physician when a resident refused prescribed tuberculosis (TB) medications. For one resident with severe cognitive impairment and multiple diagnoses including TB, anemia, hypertension, and mobility issues, there were multiple documented refusals of critical medications such as isoniazid, pyridoxine, and rifampin over several dates. Despite these refusals, there was no documentation in the resident's medical record or progress notes indicating that the physician had been notified of the refusals, as required by facility policy. Interviews with staff revealed that the nurse would attempt to re-administer the medications later and only notify the physician after three consecutive days of refusal, which was not in line with the facility's policy. The DON confirmed that although the physician visited frequently and was verbally informed, the refusals were not documented in the progress notes. The facility's policy specifically required that detailed information about treatment refusals be documented in the medical record and that the healthcare practitioner be notified of any refusal of treatment.