Failure to Notify Physician of Change in Condition and Missed Medications
Penalty
Summary
The facility failed to notify a physician of changes in condition and missed medication doses for two residents. For one resident with multiple diagnoses including dementia, depression, anxiety, and cardiovascular conditions, the Medication Administration Record showed missed and refused doses of olanzapine, melatonin, and pravastatin on several dates. There was no documentation explaining why the medications were not administered on one occasion, nor any evidence that the physician was notified of the refusals or missed doses. The Assistant Director of Nursing confirmed the lack of documentation and was unable to determine why the medications were not given or if the physician had been informed. For another resident with diagnoses such as vascular dementia, chronic kidney disease, and a history of cerebrovascular events, a nursing progress note documented a low blood pressure reading. The clinical record did not show that the medical provider or family was notified of this low blood pressure. Interviews with nursing staff and the Director of Nursing confirmed that the nurse should have re-checked the blood pressure and notified the physician, but there was no evidence this occurred. Facility policies required notification of physicians and families for acute condition changes and documentation of medication refusals, which was not followed in these cases.