Failure to Notify Physician of Changes in Condition and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate notification of physicians regarding significant changes in residents' conditions and medication administration. For one resident with type 2 diabetes and end stage renal disease, blood sugar readings exceeded 400 on two occasions, but there was no documentation that the physician or nurse practitioner was notified as required by the physician's order. Another resident with dementia, diabetes, hypertension, and acute kidney failure had a blood pressure medication withheld on two occasions without any documented notification to the physician or nurse practitioner, despite the absence of parameters for holding the medication. Additionally, a third resident with congestive heart failure and diabetes had insulin doses either refused or held, but there was no documentation that the physician was informed of these missed doses. In each case, interviews with the Director of Nursing confirmed that the appropriate notifications to the physician or nurse practitioner were not made as required by facility policy and physician orders.