Failure to Notify Physician/NP of Missed Treatments and Medication Unavailability
Penalty
Summary
The facility failed to notify the physician or nurse practitioner (NP) of significant changes in the treatment needs of two residents, resulting in ineffective management of pain and medication administration. For one resident with a history of urinary tract infection, urinary retention, and urethral erosion, staff did not inform the NP about the resident's uncontrolled pain during indwelling urinary catheter care or about 34 missed doses of prescribed Lidocaine gel for genital pain. Despite the resident frequently expressing pain during catheter care and the medication being unavailable for an extended period, there was no documentation or evidence that the NP was notified of the missed doses or the resident's ongoing pain. The NP confirmed she was unaware of the situation and would have reassessed the pain management plan if informed. Another resident, admitted with multiple complex diagnoses including myasthenia gravis, malignant melanoma, and chronic respiratory failure, did not receive several critical medications, including an antiviral, an immunosuppressant, and an artificial saliva product, due to pharmacy supply issues. The resident reported persistent symptoms related to the lack of these medications, such as dry mouth and double vision. Facility staff documented the medications as "not available" over an extended period but did not consistently notify the NP or the prescribing oncologist about the ongoing unavailability. The NP stated she was only made aware of the issue after surveyor inquiries and had not been kept informed of the continued lack of medication administration. The facility's own policy required timely notification of the physician or NP when there is a need to significantly alter a resident's medical treatment or when a resident's condition changes. In both cases, staff failed to follow this policy, resulting in prolonged periods where residents did not receive necessary pain management or essential medications, and the responsible medical providers were not given the opportunity to intervene or adjust care as needed.